Medical Release Form
 

CEDAR BROOK ACADEMY
LIABILITY AND MEDICAL RELEASE FORM


     I understand that CBA sponsored events including, but not limited to field trips and group classes, are organized and supervised by CBA staff.  In the event of mishap or injury, as a condition of my child / children's participation, I release Cedar Brook Academy and the host organizations, their officers and agents from all liability for accidental injury to my child / children while attending or participating in school functions.

     In the event of injury resulting in the need for emergency care, I hereby authorize the staff of Cedar Brook Academy to contact the appropriate medical personnel needed.  If the situation so develops that my child must be administered medication or taken to the nearest medical facility, and I am not available for immediate approval, I hereby grand authority to the staff of Cedar Brook Academy to make such decisions.

 

 

  

(Parent or Guardian)

(Date)

 

 

(Home Phone Number)

(Work Phone Number)

 

 

(Cell Phone Number)

 

Names and ages of child / children in CBA:

 

 

 

 

 

 

 

 

Doctor's Name     Phone Number   
Please list any specific medical conditions or requests below




 

 

Copyright © Cedar Brook Academy 2008

  23700 Stringtown Road
  Clarksburg, MD 20871
Phone: 301-528-6706
Fax: 301-528-6704
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