XZone Medical Release Form 2023 - 2024

This form is for students in the Nursery - 5th grade. This is an annual form. This form will expire September 2024.

Thank you for filling it out completely as the information is critical in case of an emergency.

Today's Date

YYYY

Student's Name

First Name

Last Name

Grade in School

Name Of Current School

Allergies

(If none, please write NONE)

Activities

My student can fully participate in all activities, except for the following: (If none, please write NONE)

Parent(s) Information

Parent #1 Name

First Name

Last Name

Parent #1 - Phone Number

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent #2 - Name

First Name

Last Name

Parent #2 - Phone Number

(###)

###

####

Parent #2 - Address (If address is different than Parent #1)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name (Other than Parents)

First Name

Last Name

Relationship to the student

Emergency Person's Phone Number

(###)

###

####

Pursuant to California Family Code §6910, I, ________________________________, a parent having legal custody of _________________________________, a minor child, hereby authorize the adult leaders of the La Jolla Pres youth program into whose care such minor child has been entrusted, to consent to any X-ray examination (or similar examination such as by CAT scan), anesthetic, medical or surgical diagnosis or treatment and hospital care to be rendered to the minor under the general or special supervision and upon the advice of a physician and surgeon licensed under the provisions of the Medical Practice Act or to consent to an X-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered to the minor by a dentist licensed under the provisions of the Dental Practice Act. I agree to pay any and all costs for the foregoing.

Student's Name

Medical Insurance Provider

Insurance certificate number and/or group number.

Primary Care Physician

Primary Care Physician Office Number

(###)

###

####

I agree that the forgoing is true and correct. I give consent for my child to be treated.

Yes

Parent Signature