Today's Date

YYYY

Student Name

First Name

Last Name

Student Date of Birth

YYYY

Student Age

Student Grade

Email Address

Medical Release

I hereby give permission for representatives of Dyslexia Resource Center (DRC), a South Carolina 501(c)(3) tax-exempt nonprofit entity, to administer and/or obtain appropriate medical attention to my child in the event of any accident, illness, or injury. In the event of an emergency, 911 will be called and I will be responsible for any and all costs of medical coverage and treatment provided not covered by my child’s insurance. I hereby release and hold harmless Dyslexia Resource Center from any claim whatsoever which arises or may hereafter arise on account of any first aid, treatment, or medical service rendered to my child or obtained for my child. *

Health Information

Does student have any allergies?

Yes

List all student allergies. If none, write NONE.

Does student have an epi-pen or inhaler?

Epi-Pen

Inhaler

Both

Neither

Does student have any medical issues or special needs that program leaders need to be aware of? If so, please describe. If no, write NONE.

Health Insurance Information

Health Insurance Company

Health Insurance Policy Number

Policy Holder Name

First Name

Last Name

Policy Holder Date of Birth

YYYY

Policy Holder Relationship to Student

Emergency Contact Information

Emergency Contact - Primary

First Name

Last Name

Emergency Contact - Relationship to Student

Emergency Contact - Best Number

(###)

###

####

Signature of Parent/Guardian

Child Pick Up Notice

All students must be signed in/out by a parent/guardian. Students will not be released unattended to the parking lot. If your student will be riding with someone other than a parent/guardian, please let us know.

The following person(s) is authorized to pick my child up after programs at the Dyslexia Resource Center.

First Name

Last Name

First Name

Last Name

If I cannot pick up my child from tutoring I will make arrangements for one of the above people to pick him/ her up promptly. .

Please write your full name and date below.

Electronic Signature

I acknowledge that all information typed in this form is true to the best of my knowledge. By using this electronic form, I agree that my typed name where requested serves as my signature.