Medical Release Form

Student Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

School

Parent Name

First Name

Last Name

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Alternate Emergency Contact

First Name

Last Name

Alternate Emergency Contact Phone

(###)

###

####

Physician Name

First Name

Last Name

Physician Phone

(###)

###

####

Insurance Carrier: Name, Address & Policy Number

Allergies/Food Allergies

Current Medical Issues

Medication Being Used (include dosage/frequency)

Authorization for Treatment of Minor

I hereby consent to the nurse or physician selected by the Tour Director representing Slotsy Tours and Travel Inc. to perform routine tests and treatment for the health of my child. In the event I cannot be reached in an emergency, I hereby give permission for the physician selected by the Tour Director representing Slotsy Tours and Travel Inc. to hospitalize, secure proper treatments for, and to order injection, anesthesia, or surgery for my child as named above. In the event of any emergencies during the tour, the undersigned hereby grants authority to be exercised at the discretion of Tour Director representing Slotsy Tours and Travel Inc. or chaperone to dispense over-the counter medication.

I do consent

Parent/Guardian Name

First Name

Last Name

Today's Date

MM

DD

YYYY