Medical Release

2007-08

Name Age Birthdate .

Address .

City State WA Zip Code .

Please complete the questions listed below. It is imperative that we have some medical information in order to best care for you in case of emergency.

Do you have a chronic health problem that may require medication? Yes No .

If so, what is it? .

(Asthma, Diabetes, Headaches, etc.)

Will you have this medication with you? .

Name of the medication: .

Do you have any known allergies? .

If so, what? .

(Penicillin, Aspirin, Bee stings, etc.)

The following needs to be completed by Parent/Guardian

I give my permission for emergency medical treatment to be administered to my child, ,

as deemed necessary by the coach/instructor and proper medical authorities.

Signed Date .

Home phone .

Business phone .

Physician’s name .

Physician’s phone .

Port Angeles High School

304 East Park

Port Angeles, WA 98362

Phone: 360-565-1547

Fax: 360-452-0256