Armens - Medical Consent Release | Holy Martyrs Ferrahian High School

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Holy Martyrs Ferrahian High School

Սրբոց Նահատակաց Ֆերահեան Երկրորդական Վարժարան

Holy Martyrs Marie Cabayan Elementary School

Սրբոց Նահատակաց Մարի Գապայեան Նախակրթարան

Full Name*

Answer required for "Full Name"

School Name*

Answer required for "School Name"

Address

Street Address

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City

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Zip/Postal

Answer required for "Zip/Postal"

Cel Phone #: (including Area Code)*

Number Required

Business Phone #: (including Area Code)

Number Required

Emergency Phone #: (including Area Code)*

Number Required

Athlete's Birthday*

Answer required for "Athlete's Birthday"

If yes, please specify

Answer required for "If yes, please specify"

Any other medical issues or doctor prescibed medication your child takes (please list)

Answer required for "Any other medical issues or doctor prescibed medication your child takes (please list)"

Special diet as prescribed by a doctor?

Answer required for "Special diet as prescribed by a doctor?"

Yes

If yes, specify

Answer required for "If yes, specify"

Any excersice your child should not do?

Answer required for "Any excersice your child should not do?"

Yes

If yes, please specify

Answer required for "If yes, please specify"

Is your child covered by Insurance?

Answer required for "Is your child covered by Insurance?"

Yes

No. Give details below - (very important)

Give details

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Name of insurance company

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Employee Name

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Group #:

Answer required for "Group #:"

Policy #:

Answer required for "Policy #:"

We agree to hold HOLY MARTYRS ARMENIAN ELEMENTARY & FERRAHIAN ARMENIAN SCHOOL harmless of any liability resulting from injuries or loss of property sustained by me/our child during any function. I/We give consent for our child to receive medical treatment by a registered or licensed physician when deemed necessary.

FATHER/GUARDIAN signature required*

Signature Required

Date*

Answer required for "Date"

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Armens - Medical Consent Release