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Welcome
Academics
Admissions
Gallery
Extracurricular
Portal Login
Contact
Medical Release Form
Name
*
First Name
Last Name
Social Security #
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date
MM
DD
YYYY
Medical Insurance Policy
*
Physician's Name
*
First Name
Last Name
Physician's Phone
*
(###)
###
####
Allergies to Medications
*
Allergies (other)
*
Please note all conditions for which your child is currently receiving treatment
*
Note any other significant medical information
*
Is your child up to date with vaccines?
*
Yes
No
Does your child have an exemption waiver?
Yes
No
Emergency Contact
*
Phone
(###)
###
####
Additional Contact
*
Phone
(###)
###
####
AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S)
I do hereby state that I have legal custody of the aforementioned Minor. I grant my authorization and consent for AIM Academy Staff to administer general first aid treatment for any minor injuries or illnesses experienced by the Minor. If the injury or illness is life threatening or in need of emergency personnel to attend, transport, and treat the Minor and to issue consent for any X-Ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. I agree to assume financial responsibility for all expenses of such care. It is understood that this authorization is given in advance of any such medical treatment but is given to provide authority and power on the part of AIM Academy Staff in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel.
Parent/Legal Guardian Signature
*
Printed Name
*
First Name
Last Name
Date
MM
DD
YYYY
Thank you!