Personal Information Form

I release you from all legal responsibility or liability that may arise from this authorization which includes both verbal and written consent to access my/son or daughter’s personal health information if needed in the case of an emergency or health concern.

Parental/Guardian Information:

General Information

Sex: MaleFemale

In case of emergency please notify:

Medical History:

It is important that the history be as complete and as accurate as possible. Students should indicate both past and current medical problems, including surgeries as well as any significant injuries.

Allergies: (List symptoms of all drug, environmental and food sensitivities).

Current Medications (List all medications you presently use)
Please include Dosage, Frequency, Prescription & Condition.

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