Parental Consent And Release Of Liability Agreement Page 2
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5Health Insurance Information
Private insurance information must be provided, if applicable. If a participant does not have private health
insurance, please be advised that, should a participant require medical attention, you are responsible for
paying any costs not covered by insurance.
Participant’s Name: _______________________________ Participant’s SS Number: ________________
Participant’s Address: __________________________________________________________________
Participant’s Phone Number: ___________________________________ Date of Birth: ______________
Insurance Company Name: ____________________________________ Effective Date: _____________
Address of Insurance Company: __________________________________________________________
Policy Holder’s Name: _________________________________________ Policy #: ________________
Policy Holder’s Address: _______________________________________ Group #: ________________
Relationship to Participant: _____________________________________ Contact #: _______________
Name of Primary Care Physician: ________________________________ Contact #: _______________
I hereby authorize the release of any medical information which might be needed in connection
with payment for medical services.
____________________________________
________________________________
Parent/Guardian Signature
Date
I request that payment under my medical insurance program be made directly to the provider on
any bills for services rendered by that provider. I understand that I am financially responsible for
fees not covered by this authorization.
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