Parent name and cell phone number:

Students' names (first and last):

Medical Insurance information, policy and group number for family, or for individual members, if different for each:

Family physician and phone number:

Medical conditions, please note which child:

Allergies, please note which child:

In case I cannot be reached, contact:

Name, phone, relation to student

By typing my name below,

I hereby give my permission for any and all medical attention necessary to be administered to my child(ren) in the event of an accident, injury, sickness, etc., under the direction of a designated representative from Creative Home Educators’ Support Services, inc., until such time as I may be contacted. This release is effective until revoked in writing by me for the current school year. I also hereby assume the responsibility for payment of such treatment.