Medical Treatment Release Form

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-­‐   S AMPLE   -­‐  
 
Each   m inor   p articipant   a nd   t heir   p arent/legal   g uardian    
Must   s ign   a nd   c omplete   t his   f orm   b efore   t he   p articipant   c an   p articipate.    
 
Medical   T reatment   R elease   F orm    
 
Health   I nsurance   C arrier:   _ ________________________________________________   P olicy   #   _ ____________________________________________________                          
Insurance   P hone   N umber:   _ _______________________________________________________________________________________________________________  
I,   t he   u ndersigned   p arent/legal   g uardian,   h ereby   g ive   m y   p ermission   f or   m y   s on/daugher:   _ ______________________________________  
to   p articipate   i n   a ll   a ctivities   s ponsored   b y:   _ _____________________________________________________   f rom:   _ _____________to   _ ______________.  
In   t he   e vent   o f   a n   i njury/illness,   I   h ereby   g ive   p ermission   i n   a dvance   f or   a ny   e mergency   t ransporation   a nd   m edical   t reatment  
as  deemed  necessary  by  qualfied  medical  or  paramedical  personnel  including  surgical  treatment  and/or  hospitalization  and  
hold   t he   s ponsoring   o rganization:   _ __________________________________________________________,   a nd   i ts   r epresentivties   h armless   i n   t he  
exercise   o f   t his   a uthority.    
 
_______________________________________________________                                   _ ___________________________________________________                       _ ___________________  
Please   p rint   f ull   n ame   o f   P articipant    
 
                          S ignature   o f   P articipant                    
 
                            D ate  
_______________________________________________________                                   _ ___________________________________________________                       _ ___________________  
Please   p rint   f ull   n ame   o f   P arent/Legal   G uardian                                   S ignature   o f   P arent/Legal   G uardian                    
                            D ate  
 
Participant’s   A ddress:   _ __________________________________________________________________  
City:   _ __________________________________________   S tate:   _ ____________   Z ip:   _ _________________  
Age:   _ _______   B irthdate:   _ _______________________   G ender:   _ _______________  
Family   E mail:   _ ____________________________________________________________  
EMERGENCY   N OTIFICATION    
                                A LTERNATE   C ONTACT  
Name:   _ _________________________________________  
Name:   _ ____________________________________________________  
Home   P hone:   _ _________________________________  
Home   P hone:   _ ____________________________________________  
Work   P hone:   _ _________________________________  
Work   P hone:   _ _____________________________________________  
Cell   P hone:   _ ___________________________________                           C ell   P hone:   _ _______________________________________________  
Describe   any   health   conditions   requiring   medication,   treatment,   or   special   restrictions.   List   any   medication   that   the  
participant   is   currently   taking.   If   the   participant   is   under   medication,   please   check   to   make   sure   that   they   bring   their  
medication   i n   t he   b ottle   p rescribed   b y   t heir   p hysician   a nd   g ive   t o   t he   p erson   r esponsible   f or   a dministering   t heir   m edication.    
Is   t he   p articipant   a llergic   t o   a ny   m edications,   f ood,   o r   b ee   s tings?   I f   s o,   p lease   l ist:   _ _________________________________________________  
If   a llergic   t o   b ee   s tings,   d oes   y our   c hild   h ave   a n   e pi   p en?   _ ___________________________  
Immunization   R ecords-­‐Most   R ecent   D ate:   D TP   ( Tetanus)   -­‐   M MR   H ib   ( Haemophilus   i nfluenzae)     -­‐   H epatitis   B       -­‐       P olio  
 
 
 
 
                                    D ate:   _ _________           D ate:   _ _________________________________           D ate:   _ ________       D ate:   _ _______  

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