Melrose Christian Middle School

Admission & Medical Release Form

4879 Colonial Rd.
Roseburg, OR 97471
(541) 784-7754
Students full legal name_________________________________________
Age___________ DOB__________________________________________
Address_______________________________________________________
City______________________________ Zip________________________
Ethnicity: White/Black/Hispanic/Asian/Pacific/American Indian
LEGAL PARENT OR GUARDIAN
Fathers Name:________________________________________________
Mailing Address (if different)_____________________________________
Phone #: During school:_________________________________________
Home #:___________________ Cell #:_____________________________
Work#:____________________ Employer:__________________________
Fathers email address:___________________________________________
Lives with student?_______
Mothers Name:_______________________________________________
Mailing Address (if different)_____________________________________
Phone #: During school:_________________________________________
Home #:___________________ Cell #:_____________________________
Work#:____________________ Employer:__________________________
Mothers email address:__________________________________________
Lives with student?_______

Guardians Name:_____________________________________________
Mailing Address (if different)_____________________________________
Phone #: During school:_________________________________________
Home #:___________________ Cell #:_____________________________
Work#:____________________ Employer:__________________________
Guardians email address:________________________________________
Lives with student?_______
Mail from the school should be addressed to:_______________________
EMERGENCY CONTACT
If case of an emergency or school closure, please provide us with names,
addresses, and phone numbers of contacts if the school cannot contact you.
Emergency contact #1:
Name & address:_______________________________________________
Relationship:___________________________________________________
Phone numbers(s)_______________________________________________
Emergency contact #2:
Name & address:_______________________________________________
Relationship:___________________________________________________
Phone numbers(s)_______________________________________________
MEDICAL INFORMATION
Are there any particular medical problems your child may be experiencing
which his/her teacher should be aware of?
(Please circle)

Allergies
Frequent Colds
Frequent Stomach Upset
Diabetes
Epilepsy
Hay fever

 Heart Condition

Chronic Asthma
Physical Disabilities
Sensitivity to sugar/caffeine
Sensitivity/allergic reaction to bee/wasp stings
Wears glasses
Medication taken during school
Date of last tetanus shot___________

Explanation for any of the above:

In the event that I cannot be reached in an emergency during the dates specified on this
form, I hereby give my permission to the physician or dentist selected by Serena Fink of
Melrose Christian School House to hospitalize, to secure proper treatment, and/or order
an injection, anesthesia, or surgery for my son or daughter as deemed necessary.
Liability Release
Every activity at this school is carefully planned and adequately supervised by Serena
Fink and possibly other carefully selected adults (Faye Fink (my mother-in-law), parents
of children attending this school, grandparents, etc) By signing this form, the parent or
guardian agrees to assume and accept all risks and hazards inherent in school-related
activities. They also agree not to hold this school or volunteers liable for damages,
losses, or injuries to the person or property of the undersigned. The parents or guardians
understand that they are signing for the minor listed on this form and the signature is for
both a medical and a liability release.

Parent/Guardians
signature____________________________Date:_______
Parent/Guardians
signature____________________________Date:_______