ALCA Student Release Form

Medical Information and Release
Field Trip and Photo Release
Pick-up Release
Driving Release

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Student Information

Student's First Name *

Student's Last Name *

Entering Grade Level *

Parent Email Address *

Emergency Contact Information

Physician's Name *

Physician's Phone *

Emergency Contact Name (other than parent) *

Relationship to Student *

Contact Phone *

Emergency Permission Agreement

Should an emergency arise in which my child will need to be transported to a local hospital, I give my consent for the transport to take place. If I am not able to be reached, I give my consent for my child to be medically and/or surgically treated by medical professionals to whatever extent is necessary to the wellbeing of my child.

Affirmation *

I Agree

Digital Signature *

Please enter your full legal name

Date *

Time *

Permission to Administer Medication

There are times when a child may need over the counter medication. We are able to administer the following medications only if we have a signed permission slip from the parent. Please check the medication that we are able to administer to your child and sign the release. In most cases, generic brands will be used.

Please select any that are acceptable *