Today's Date *
Today's Date
Student Name *
Student Name
Student Date of Birth *
Student Date of Birth
Medical Release
Health Information
Does student have any allergies? *
Does student have an epi-pen or inhaler? *
Health Insurance Information
Policy Holder Name *
Policy Holder Name
Policy Holder Date of Birth *
Policy Holder Date of Birth
Emergency Contact Information
Emergency Contact - Primary *
Emergency Contact - Primary
Emergency Contact - Best Number *
Emergency Contact - Best Number
Media Release
The Dyslexia Resource Center - Tutor Eau Claire may take photographs/video for training purposes, to promote programs and community outreach. Photos/videos may be posted to the DRC’s website, shared on the DRC Facebook page, and/or shared for stories with media outlets. To protect your right to privacy, we need your permission to take photographs/video of your child.
Child Pick Up Notice
All students must be signed in/out by a parent/guardian. Students will not be released unattended to the parking lot. If your student will be riding with someone other than a parent/guardian, please let us know.
The following person(s) is authorized to pick my child up after programs at the Dyslexia Resource Center. *
The following person(s) is authorized to pick my child up after programs at the Dyslexia Resource Center.
Please write your full name and date below.
Electronic Signature
*