Lighthouse Learning Home School Co-op

Emergency Medical Release Form

2010/2011

 

Name: _______________________________________________________________
 Address:__________________________________________________________________________
Home Phone: ____________________________
Father’s work phone: ____________________________ Cell phone: _________________________
Mother’s work phone: ___________________________ Cell phone:__________________________
Enrolled Children: First and Last Name Does child have any serious health problems or allergies?
___________________________________________ _________________________________
___________________________________________ _________________________________
___________________________________________ _________________________________
___________________________________________ _________________________________
___________________________________________ _________________________________
___________________________________________ _________________________________
___________________________________________ _________________________________
___________________________________________ _________________________________
Emergency Contacts (please list at least two):
Name: ______________________________________ Phone: ______________________________
Name: ______________________________________ Phone: ______________________________


May we administer regular first aid to your child/children in the event of an injury? ______________
May we call an ambulance on behalf of your child/children if deemed necessary? ______________
Do you authorize hospital or doctor to administer necessary medical treatment? ______________


Signature:_________________________Date:______________(I am responsible for the above authorizations)


Please supply the following information for each child you are registering with Lighthouse Co-op. You may put the information on the back of this form.
___ My son/daughter is covered by a medical insurance policy.
Policyholder’s Name______________________________Policy holder’s SSN___________________
Insurance Company Name ______________________________________________
Insurance Company Address____________________________________________
City____________________State______Zip_________
Insurance Company Phone Number______________________________________
Policy Identification Number___________________________________________
____My son/daughter is NOT covered by a medical insurance policy.