2025-2026
UNIVERSAL MEDICAL INFORMATION/EMERGENCY CONTACT
RELEASE AND CONSENT FORM
School
School Year
Teacher Name
Grade Level
Name of Student
First Name
Last Name
Student Address
Street
City
State
Zip
Home Telephone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Email Address
*
example@example.com
Siblings at School
Name
First Name
Last Name
Grade
Teacher
Name
First Name
Last Name
Grade
Teacher
Name
First Name
Last Name
Grade
Teacher
Student lives with
Parent 1
Parent 2
Guardians
Parent
or Legal Guardian's Information
Name
*
First Name
Last Name
Work Address
Street
City
State
Zip
Home Address (if different from child's)
Street
City
State
Zip
Home Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Work Telephone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent
or Joint Legal Guardian's Information
Name
Last
First
Work Address
Street
City
State
Zip
Home Address (if different from child's)
Street
City
State
Ziip
Home Phone (If different from child’s)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Work Telephone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
UNIVERSAL MEDICAL INFORMATION/EMERGENCY CONTACTRELEASE AND CONSENT FORM
Emergency Contacts – your signature (*) authorizes these people to pick up your child from school:
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Telephone Numbers
*
Please enter a valid phone number.
Format: (000) 000-0000.
Signature
*
Relationship to child
Student Medical Information:
Primary Physician:
Physician Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Physician:
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Conditions: (e.g., diabetes, epilepsy, heart conditions, etc.)
Disabilities
Allergies:
Medications:
Allergies to Medications:
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Submit
Should be Empty: