Student Activities Contract & Medical Form

PARENTAL CONSENT AND HEALTH FORM
Name of Student: _________________________________________________
Home Address: ___________________________________________________
Home Phone: _________________Mobile Phone: _______________________
Nationality: _______________ Passport Number: _______________________
Father’s Name: _____________________Signature:______________________
Mother’s Name: ____________________Signature:______________________
Please list any special medical instructions, which will be beneficial for the
coaches/sponsors to have regarding your son/daughter:
__________________________________________________________________
Please list any allergies your son/daughter might have:
Please indicate any medications that your son/daughter is taking or occasionally
takes. Also indicate dosage and frequency:
___________________________________________________________