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Medical Release Form

This 3 sentence summary provides the key details from the Student Medical Release Form: The form collects a student's name, contact information, medical details like allergies and conditions, and photo/artwork consent to be used for education and promotions. It also requires parents to initial that they understand any injuries occurring during art classes are not the responsibility of the teacher or program. Parents must sign and date the fully completed form before a student can attend class.

Uploaded by

Chrissy Colbert
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
599 views

Medical Release Form

This 3 sentence summary provides the key details from the Student Medical Release Form: The form collects a student's name, contact information, medical details like allergies and conditions, and photo/artwork consent to be used for education and promotions. It also requires parents to initial that they understand any injuries occurring during art classes are not the responsibility of the teacher or program. Parents must sign and date the fully completed form before a student can attend class.

Uploaded by

Chrissy Colbert
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Student Medical Release Form.

This form must be entirely complete before the student is allowed to attend class.

Name: SEX: ❏M ❏F
First MI Last
Address: City: Zip:

Phone: Age: Birth date: / /

School: Grade:

Parent’s Name: Phone:

Email Address:____________________________________________________

Alternate Contact:____________________________________Phone:______________

Please read and initial the following:


• I give consent and authorize Chrissy Colbert to use my child’s photograph and/or
artwork for education and public relations purposes on her website/blog. ❏Yes ❏No Initials
_______

List any allergies to food, insects, medication, etc. Describe allergic reactions and their severity.

Are there any special needs or concerns of your child that I should be aware of?

Please read carefully the following and initial.


Should any injury occur during or as a result of participation in any Squiggles Children’s Art
Class, workshop, camp or program I agree to indemnify and hold harmless Chrissy and all her
employees, instructors, and volunteers connected with Squiggles Children’s Art Classes.
Initials ________

Signature:____________________________________________________ Date:__________________

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