Annual Medical Consent and Liability Form

Please fill out this form and click submit.

Child's Name:

*

Birth date:

*

Gender:

*

Please select one option.

Male Female

Grade (in or just completed):

*

Please select one option.

7 8 9 10 11 12

Address

*

Phone

*

Emergency Notification:

Name:

*

Home Phone:

Cell Phone:

*

Work Phone

Alternate Contact:

Name:

*

Home Phone:

Cell Phone:

*

Work Phone

Do you have medical insurance which covers your child?

*

Please select all that apply.

Yes No

Insurance Company:

*

Policy Number:

*

Health History: (Please list any pertinent health history information)

Activity Restrictions:

Description

Please fill out this form and click submit.

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