Medical Release and Emergency Contact Form

Please Note:

Andy’s staff will make every effort to reach you or the designated Emergency Contact Person in the case of an emergency. However, if no one can be reached, by submitting this form you are giving your permission for the Andy’s staff to secure proper medical treatment for your child.

Parent/Guardian Completing Form *
Parent/Guardian Completing Form
Child's Name *
Child's Name
Date of Birth *
Date of Birth
Child's Phone (if applicable)
Child's Phone (if applicable)
First Parent/Guardian
First Parent/Guardian Name *
First Parent/Guardian Name
Home Address *
Home Address
First Parent/Guardian Cell Phone
First Parent/Guardian Cell Phone
First Parent/Guardian Home Phone
First Parent/Guardian Home Phone
First Parent/Guardian Work Phone
First Parent/Guardian Work Phone
Second Parent/Guardian
Second Parent/Guardian Name
Second Parent/Guardian Name
Home Address (if different from above)
Home Address (if different from above)
Second Parent/Guardian Cell Phone
Second Parent/Guardian Cell Phone
Second Parent/Guardian Home Phone
Second Parent/Guardian Home Phone
Second Parent/Guardian Work Phone
Second Parent/Guardian Work Phone
Additional Emergency Contact
Additional Emergency Contact Name
Additional Emergency Contact Name
Additional Emergency Contact Cell Phone
Additional Emergency Contact Cell Phone
Additional Emergency Contact Home Phone
Additional Emergency Contact Home Phone
Medical Information
Primary Care Physician
Primary Care Physician
Primary Care Physician Phone
Primary Care Physician Phone
If your child has a headache or other mild pain do you give us permission to distribute label-recommended dosages of Tylenol or Ibuprofen? *
Date of Child’s last tetanus shot: *
Date of Child’s last tetanus shot: