User: The Sample Family

Sample Medical Release

indicates a required answer

Please submit ONE Medical Release form  for each student attending the Co-Op.

1. *

Student's Name (First, Middle, Last)

2. *

Student's date of birth

3. *

Parent's/Guardian's Names

4. *

Parent/Guardian's address

5. *

Parent/Guardian primary phone number

6. *

Parent/Guardian alternative phone number

7. *

Does your student have any allergies?  If yes, please list allergies.

8. *

Will your student be allowed to eat treats brought to class?

 (1 required)
Yes No
9. *

List any medical/health related concerns The Network should be made aware of. If none, please type "none".

10. *

I will contact my student's teacher and notify them of any medical/health related concerns.

 (1 required)
11. *

Doctor's name

12. *

Doctor's phone number

13. *

Preferred hospital


If your student gets injured you will allow the use of ...

Tylenol Advil
Tums/antacids Band-Aid
Ice Pack Ankle Wrap

I understand that the Co-Op takes every precaution to assure my student’s safety. However, if an accident should occur and I cannot be notified, I authorize the Co-op to seek emergency treatment at my own expense. I will not hold the Co-op or any of its representatives liable.

***IMPORTANT***  Agreement to the online forms constitutes your "digital signature", so please read carefully before agreeing to/signing the form(s). 

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