Form 3

WESTMINSTER INTERNATIONAL SCHOOL

MEDICAL RELEASE FORM

I/we give permission for the Westminster International School in Pisa to take my child/ren

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to the nearest hospital for students in the event of medical care or advice being necessary.

I/we understand that I/we will be contacted immediately if my/our child/ren need/s medical attention.  If for some reason I/we are not contactable, listed below are four (4) next-of-kin whom I/we authorize you to contact.

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I/WE authorize school personnel to obtain emergency medical care for my child/ren in the event I/WE cannot be reached if transportation by ambulance is required.

Family Physician

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Address ……………………………………………………………………………………………..….

Telephone…………………………………………………………………………………………..……

Family Dentist

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Address ……………………………………………………………………………………………….…

Telephone …………………………………………………………………………………………..…..

Preferred Hospital

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Telephone ……………………………………………………………………………………………..

(every endeavour will be made to ascertain that the child is taken to the preferred hospital, however, circumstances may push us to choose some other hospital instead of the “preferred hospital”).

Signed by Parent/s/Guardian/s

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