-‐
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:
_ _______