Parental Or Guardian Permission And Medical Release

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Parental or Guardian Permission and Medical Release
Activity
Date
Ward
Stake
Participant
Date of birth
Home telephone number
Participant’s parent or guardian
Business telephone number
Address
City
State/Province
Medical Information
Does the participant have any of the following:
Special diet
Allergies
Medication
Chronic/Recurring illness
Surgery or a serious illness in the past year
Physical conditions that limit activity
If yes, explain below. Use back if more space is needed.
I give permission for my child/youth to participate in the activity
for any accident or illness and to act in my stead in approving nec-
listed above and authorize the adult leaders supervising this activity
essary medical care. This authorization shall cover this activity and
to administer emergency treatment to the above-named participant
travel to and from this activity.
Parent or guardian’s signature
Date
6/98. Printed in the USA. 33810
Parental or Guardian Permission and Medical Release
Activity
Date
Ward
Stake
Participant
Date of birth
Home telephone number
Participant’s parent or guardian
Business telephone number
Address
City
State/Province
Medical Information
Does the participant have any of the following:
Special diet
Allergies
Medication
Chronic/Recurring illness
Surgery or a serious illness in the past year
Physical conditions that limit activity
If yes, explain below. Use back if more space is needed.
I give permission for my child/youth to participate in the activity
for any accident or illness and to act in my stead in approving nec-
listed above and authorize the adult leaders supervising this activity
essary medical care. This authorization shall cover this activity and
to administer emergency treatment to the above-named participant
travel to and from this activity.
Parent or guardian’s signature
Date
6/98. Printed in the USA. 33810

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