2023 Valley View Medical Release

Please fill out the "your name field" as the event attendee's name, not guardian's name.

Your name *

Email address *

Birthdate

Grade

Gender

Address

Mother's Name *

Mother's Cell *

Student's primary residence *

Mother's Email *

Father's Name *

Father's Cell *

Father's Email *

Emergency Contact *

(to be contacted if parent can't be reached)

Emergency Contact Cell *

Emergency Contact Relationship to Student *

Medical Insurance Company *

Policy # *

List your student's ALLERGIES to food, pollens, animals, medications, etc. *

What type of reaction does your student have to the above allergies? *

Does your child carry an inhaler?

Additional Medical Information

For your child's safety and our knowledge, is your student a good swimmer? *

If needed, I give Valley View permission to administer the medications listed below. *

Does your child wear glasses/contacts/hearing aides? *

Please list and explain any major illnesses/surgeries your child experienced in the last year. *

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