Medical

HELP Homeschool Classes 2011/2012

Medical Release Form

Child(ren’s) Information:

Name______________________________________________________ DOB___________________

Parent’s Name:______________________________________________ Phone___________ Cell_______________

Address:___________________________________________________ City:_____________State:_____________

I give permission for my above-named child(ren) to attend IEW, Exploring North America, TOTAL IEW with Wordsmith, Mad Science, Ohio History, Spanish, Musical Theater, Art, Galloping the Globe, Five in a Row, Literature and Composition, Institute for Excellence in Writing, World History, Debate, Lego Robotics 2, Architectural Design, Amusement Park Design, DaVinci Machines, Algebra 1 and 2, Algebra 8/7, Chemistry with Dr. Frank,Practical Computer Skills, Electronics, Junior Literature,Nothing But Writing, Nutri=Fit Kids, Speech and Debate, and any and all classes located at the Milford Christian Church for the 2011/2012 school years. I release Kay Goetz, Emily Carabello, Margie Nesteroff, Doug Frank, Dena Martinelli, Drake Planeterium and it's employees,, Tonya Preston, TJ Preston, Maureen Teller, Sharon Francis, Stephanie Mackris, MAry Beth Nesteroff, Terri Cofskey, Denise Owens, Teresa Hinners, Leslie Dorhout, Barb Woeste, Judy Young, Kim Conlin, Bionic Becky and/or Mad Science of Cincinnati, any and all Parent Volunteers, Milford Christian Church, and it’s staff and sponsors, from responsibility and liability for any injury or illness that my child may sustain during this activity. In the event of an emergency, I authorize the leadership of the classes, as agent for me, to consent to any emergency medical treatment such as: x-ray examination; medical, dental or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon, or dentist(as appropriate) licensed to practice under the laws of the state where the services are rendered, either at a doctor’s office or any hospital. I expect to be contacted as soon as possible.

Parents Must Complete ALL Medical Information:

Medical Insurance Company:______________________________________________ Policy #:__________________

Member’s Name:_______________________________________________

* Allergies* Must Fill out Back Page.

Family Doctor Name:____________________________________________

Phone #:_____________________

Emergency Phone Numbers:

Name

Relationship to Child

Phone Number

________________________________________________________________________________________________

Signature of Parent or Legal Guardian:_____________________________________________________________

Child’s Medical Information

Please list any food or drug allergies and any medication your child is currently taking.

This information will be kept confidential and would only be used in case of an emergency.

Child______________________________________________

Food Allergies______________________________________

Medications________________________________________

Drug Allergies ______________________________________

PLEASE INDICATE ANY OTHER MEDICAL CONDITION OR SPECIAL NEEDS BELOW

Please list any food or drug allergies and any medication your child is currently taking.

This information will be kept confidential and would only be used in case of an emergency.

Child______________________________________________

Food Allergies______________________________________

Medications________________________________________

Drug Allergies ______________________________________

PLEASE INDICATE ANY OTHER MEDICAL CONDITION OR SPECIAL NEEDS BELOW

Please list any food or drug allergies and any medication your child is currently taking.

This information will be kept confidential and would only be used in case of an emergency.

Child______________________________________________

Food Allergies______________________________________

Medications________________________________________

Drug Allergies ______________________________________

PLEASE INDICATE ANY OTHER MEDICAL CONDITION OR SPECIAL NEEDS BELOW

Please list any food or drug allergies and any medication your child is currently taking.

This information will be kept confidential and would only be used in case of an emergency.

Child______________________________________________

Food Allergies______________________________________

Medications________________________________________

Drug Allergies ______________________________________

PLEASE INDICATE ANY OTHER MEDICAL CONDITION OR SPECIAL NEEDS BELOW

Please list any food or drug allergies and any medication your child is currently taking.

This information will be kept confidential and would only be used in case of an emergency.

Child______________________________________________

Food Allergies______________________________________

Medications________________________________________

Drug Allergies ______________________________________

PLEASE INDICATE ANY OTHER MEDICAL CONDITION OR SPECIAL NEEDS BELOW