Medical Release Form

I hereby give my approval for emergency medical treatment if needed during the DHS Cheerleading Camp _______________________________________.

Child’s Name

Parent (or Guardian) Signature: _________________________________

Date: __________________________

Please provide the following information if possible:

Doctor’s Name: ______________________________________

Parent Phone #: ______________________________________

Cell #: _____________________________________________

Emergency Contact Name: ______________________ Number: ___________

Any known medical problems, allergies or restrictions:

__________________________________________________________________

__________________________________________________________________