Medical Release Form

Child Information

First Name

Last Name

Date of Birth

Allergies:

ANY MEDICATION CURRENTLY TAKEN: (Type of medication and time of administration):

Epipen (Yes or No)

Insurance Information:

Company Name:

Policy #:

Group #:

My child is able to recieve medicine administered by staff of New Destiny Academy

PARENT MEDICAL AND LIABILITY RELEASE STATEMENT

I understand that in the event medical intervention is needed, every attempt will be made to contact immediately the persons listed on the emergency contact form.

In the event I cannot be reached in an emergency, I hereby give my permission to the physician or dentist selected by the New Destiny Academy,

secure medical treatment as deemed necessary.

I understand that my insurance coverage for my child will be used as primary coverage in the event medical intervention is needed.

Thank you for your submission