Student Life Ministries

Medical Release Form

Name:______________________________ Age: ____ Grade: _____

Address: ___________________________ City: ___________ State: _____

Emergency Phone #:_______________ 2nd Emergency #:_________________

Insurance Company: _______________________________________

Policy Number: ________________ Policy Holder: __________________

Allergies: ____________________________________________________

Daily Medicine Taken: __________________________________________

Other Important Medical Information:_______________________________

____________________________________________________________

____________________________________________________________

I hereby authorize the immediate medical care necessary to be carried out for _____________________________.

I am the Father / Mother / Legal Gaurdian of the above named person, and the policy holder

of his/her health insurance.

Signed: _________________________ Date: ____________

SLM OFFICE USE ONLY

Received by: _______________________________ Date _______________