Saint Luke UMC - JAM Medical Release Form

Child's First Name

Last Name

Gender

Birthdate

Grade

Primary Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Parent/Guardian #1 First Name

Last Name

Relationship to Child:

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Home Phone Number

Cell Phone Number

Primary Email Address

Parent/Guardian #2 First Name

Last Name

Relationship to Child:

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Home Phone Number

Cell Phone Number

Email

Alternate contact in case of emergency:

(this person will be called when the above parent(s)/guardian(s) cannot be reached)

First Name

Last Name

Relationship to Child:

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Home Phone Number

Cell Phone Number

Insurance:

Provider:

Phone Number

Policy Number:

Policy Holder's ID Number

Medical Information:

Date of Last Tetanus Shot:

Physician:

Phone Number

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Dentist:

Phone Number

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Allergies your child may have:

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Please list any special health problems/concerns

Parent Signature

Date Signed

J.A.M. Medical Release Form

Alternate contact in case of emergency:

Insurance:

Medical Information: