Medical Release Form


I do hereby authorize the King’s Academy Health Center staff and/or Summer at King's Academy faculty and staff to act as agents for my child in my absence and give my consent for any and all medical attention to be administered to my child in the event of accident, injury, disease, sickness, etc. under the direction of the agents listed above, until such time as I may be contacted. Treatment may include, but is not limited to, x-ray examination, anesthetic, medical or surgical diagnosis or treatment, dental care, and care which is deemed advisable by, and is to be rendered under the general supervision of the physician or the medical staff of another facility or of the Health Center. I also assume the responsibility for the payment of any such treatment.

There may be occasion for the Health Center staff to offer intramuscular or intravascular injections as part of treatment. Injections of any kind require parent consent prior to the injection unless it is a matter of life or death.

It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care that might be required. This document is signed and provides authority to the King’s Academy Health Center staff and Summer at King's Academy staff to give specific consent to any and all such diagnosis, treatment or hospital care which a physician – meeting the requirements of this authorization – may in the exercise of his/her best judgment, deem advisable.

I hereby authorize any medical facility, which has provided treatment of my child, to surrender physical custody to the King’s Academy Health Center staff or Summer at King's Academy staff upon completion of treatment.

This authorization shall remain in effect until August 3, 2023.

Student namerequired
First name
Last name
Parent/guardian namerequired
First name
Last name

Medical Information

Student's blood typerequired
Does your child have any of the following medical condition(s)?required
Does your child have any allergies (food, insects, medicines, seasonal)?required
Has your child ever needed medical or therapeutic treatment for any mental health condition (eating disorder, ADD/ADHD, OCD, anxiety, depression or else)?required
Has your child had any surgeries, accidents, other illnesses or special problems?required
Is the child free from illness and communicable disease?required
Is the child in good health?required
Is the child's immunizations up-to-date?required

Emergency Contact Information

In case of an emergency and the school is unable to contact the parents, please notify:

First name
Last name
I am certain:required