ClearView Medical Release

We are truly excited your child/teen will be joining us on an upcoming trip or activity. We take safety seriously. Thank you for providing us with complete information and medical consent for each child/teen.
Child's Information
Child's Name *

First Name Last Name
Birth Date *

Month Day Year
Parent/Guardian Information
Parent / Guardian's Name(s) *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mobile Phone *

Area Code Phone Number
Home Phone

Area Code Phone Number
E-mail *
Other Emergency Contact (or parent)

First Name Last Name
Phone Number

Area Code Phone Number
Relationship to Child/ Family

Allergies
List all known allergies, including foods, medications, and/or latex *
Prescriptions
List all current or recent (within the last 3 months) prescription medications, dosages, and frequencies: *
Medical History
Please list and describe any other medical history or conditions we should be aware of. Examples: asthma, seizures, ADHD, etc.
Tetanus Vaccine (date, estimate if not sure): *