Table of Contents - YES Prep Public Schools

Medical Release
2012-2013
Parent/Guardian:
Please fill in this form and return to the registrar as soon as possible. Please be aware that the information
given on this form may be shared with appropriate school staff in order to have better understanding of the
health status of your child.
Student Name __________________________________________Date of Birth________________
Name of Doctor ___________________________________________________________________
Doctor Number ___________________________________________________________________
Person to contact in case of emergency________________________________________________
Emergency Phone Number__________________________________________________________
Known Allergies or other medical conditions:
Medical/Immunizations:
School policy requires all immunizations to be up to date upon enrollment.
A copy of your child’s immunization should be submitted with this record.
Parent/Legal Guardian Signature ____________________________________ Date_________________
Medical Treatment
I (We), _________________________________________________ as the parent(s) or legal guardian (s) of
______________________________________________________ acknowledge and understand that YES Prep
may not have a Nurse on my child’s campus. I (We), hereby give our full consent and permission to YES Prep
personnel to provide medical attention to my child and to seek and obtain medical care and/or treatment for
our child while participating in any school program. School staff also has our full consent and permission to
sign any authorization forms necessary to obtain medical care and/ or treatment.
Parent/Legal Guardian Signature _____________________________________ Date_________________
9