Medical Release Form
Please fill out one for each of your children currently attending HLCS
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Student Name *
Student Date of Birth *
MM
/
DD
/
YYYY
2021-2022 Grade *
Home Address, City, State, Zip *
Father name and cell number *
Mother name and cell number *
Emergency Contact name & cell phone number *
Emergency Contact name & cell phone number *
Health Insurance *
Any Allergies if yes please list *
History please check if any apply *
Required
If yes to any of the above history, please explain
List any medications taken
Family Dr and phone number *
Family Dentist and phone number *
I/we give permission for our child to receive over the counter medication (Ibprophin, Tylenol, cough drops, Benadryl etc) as needed by the office. *
Please sign below to agree that I/we the parents/guardians of the above student recognize that in a medical emergency, medical treatment may be necessary for my/our child(ren).  I/we do hereby consent to allow HLCS/the host family of my student to provide hospital care, or medical care as deemed necessary under the then existing circumstance and I/we will assume the expenses of such care. *
Have another student!! Please click the link below.
https://forms.gle/ziAdQTPSUHpMVmPy7
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