Medical Release form

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Medical Release Form

_________________________ is a member of _UIL One Act Play_ .
Name of child Organization
My child will be traveling and participating in activities with other Shallowater students during the 2010-2011 school year. I hereby give permission for the officials of Shallowater Independent School District to authorize a physician or hospital to render medical treatment as may be deemed necessary in an emergency for my child in my absence during the 2010-2011 school year.

______________________________ _______________
Signature of parent/guardian Date

Address
Medical Insurance Co. _____________________________ Policy # _______________
Allergies _______________________________________________________________
Current Medications/ Conditions ___________________________________________


Current Physician ___________________________ Phone _____________________
Emergency Phone Numbers:

Name Work Phone Cell

Home phone Other numbers

Closest Relative _________________________________________________________
Name Phone