DCS Retreat Permission to Treat/Medical Release

Parent Name*

First

Last

Parent Cell Phone*

Email*

Student Name*

First

Last

Grade

I give consent for my child to receive any necessary treatment, including first aid, diagnostic procedures, and medical treatment that may be provided by treating physicians, nurses, and other healthcare providers in order to insure the health and safety of my child.

I understand that my child cannot have any medication with them. If they require medication while on the retreat, I will provide them in an original labeled container and complete the medication waiver to the school by Wednesday, September 11, 2024.

Consent*

YES

Insurance Provider*

Policy/Group Number*

Food, Medication, or Environmental Allergies

Medical or Physical Limitations

In the event of an emergency, if a parent cannot be reached, please contact:

Emergency Contact

Cell Phone

Relationship

Comments/Notes

DCS Retreat Medical Release Form