SMOKY VALLEY HOME EDUCATORS CO-OP MEDICAL RELEASE

Family Last Name _____________________________

Father’s Name _______________     Mother’s Name _________________

Father’s Phone Number                      Mother’s Phone Number

          Home _________________             

          Work _________________              Work ____________________

          Cell ___________________             Cell _____________________

Children’s Names            Birthdate/Age        Allergies/Medical Problems?

________________      _____________   _________________________

________________      _____________   _________________________

________________      _____________   _________________________

________________      _____________   _________________________

Emergency Contact _____________________________________________

          Relationship to Children ____________________________________

          Phone Numbers:    Home ______________ Work ________________

                                      Cell _______________

Name of Family Doctor ___________________ Phone Number _________

Name of Health Insurance _______________________________________

          Policy Number ___________________________________________

          Name of Insured __________________________________________

I, _________________________ (parent/guardian) of above children (minors) understand above children will be supervised during co-op classes, choir, and band and that if serious injury or illness develops, medical and/or hospital care will be given.  I hereby give my permission to the attending physician to perform the following, but not limited to, activities:  hospitalization, diagnosis including taking specimens and x-rays, giving blood transfusions, injections, and medications, anesthesia, and surgery for my child.  I affirm that the information set forth above is true and correct to the best of my knowledge.  I also understand that the leaders of Smoky Valley Home Educators Co-op will attempt to contact me prior to securing medical treatment, but that this consent is given in case I am not available in an emergency.

Parent Signature  @ ____________________________________  Date ____________