MEDICAL INFORMATION AND RELEASE FORM:

In case of emergency and parents/guardian cannot be reached:
Name________________________ Relationship________________ Phone #: ___________________
Name________________________ Relationship________________ Phone #: ___________________
Doctor’s Name: __________________________________________ Phone #: ___________________
Health Insurance: _____________________ Policy #: __________________________
Does your child have any intolerance to drugs or medication?
If so, specify: ___________________________________________________________
Any previous illness or injury the staff should be aware of?
If so, are there any restrictions? ____________________________________________

I, hereby release Dance Movement Academy instructors and volunteers to render temporary first aid to my child in the event of any injury or illness, and any necessary medical assistance, including transportation and hospitalization.

WWW.DMA-KBG.COM
DI RODIN- Director Tel.: 479-3273 DiRodin@hawaii.rr.com