indicates a required answer
Please submit ONE Medical Release form for each student attending the Co-Op.
Student's Name (First, Middle, Last)
Student's date of birth
Parent/Guardian primary phone number
Parent/Guardian alternative phone number
Does your student have any allergies? If yes, please list allergies.
Will your student be allowed to eat treats brought to class?
List any medical/health related concerns The Network should be made aware of. If none, please type "none".
I will contact my student's teacher and notify them of any medical/health related concerns.
Doctor's phone number
If your student gets injured you will allow the use of ...
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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