HIGH Day Medical Information

MEDICAL RELEASE INFORMATION

Although it our mandatory policy that parents remain with their children during HIGH Day, because it is sometimes possible for children to attend under the supervision of a "substitute" mom, we need to keep your medical information on file for emergency purposes. Please rest assured this info is kept in the strictest confidence. Thanks.

Family Name:

Emergency Contact Info:

Doctor Contact Info:

Insurance Company & Phone Number:

Policy Holder Name:

Policy Number:

Child 1 Name/ID Number:

Child 2 Name/ID Number:

Child 3 Name/ID Number:

Child 4 Name/ID Number:

Child 5 Name/ID Number:

Family Name:
Emergency Contact Info:
Doctor Contact Info:
Insurance Company & Phone Number:
Policy Holder Name:
Policy Number:
Child 1 Name/ID Number:
Child 2 Name/ID Number:
Child 3 Name/ID Number:
Child 4 Name/ID Number:
Child 5 Name/ID Number: