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Preschool Medical Release Form
Name of parent filling out form:
First
Last
Your Email
Child's Name
First
Last
Does this child have any food allergies?
No
Yes
Type of reaction:
Is an Epi-Pen required/prescribed by a doctor?
No
Yes
If yes, parent is responsible for providing the Epi-pen to be stored at school.
Does this child have any asthma?
No
Yes
Asthma triggers/symptoms
Is an inhaler required/prescribed by a doctor?
No
Yes
If yes, parent is responsible for providing the inhaler to be stored at school.
Does this child have any chronic or medical conditions/illnesses?
Seizures?
Cardiac Condition
Type 1 Diabetes
Type 2 Diabetes
Other
Other Condition, please specify:
Please list medications related to any health condition:
Please list any other important information to help us better care for your child while at school
This information is correct to the best of my knowledge. If parent cannot be notified and emergency care is necessary I hereby give my permission for this student to be transported to the nearest hospital and I give permission for the hospital to give emergency threaten as may be needed. I will assume responsiblity for all fees incurred by such emergency:
Initial Here
*
Today's Date
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Day
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