Permission Slip And Medical Release Form (Page 2 of 2) in pdf

Permission Slip And Medical Release Form Page 2

Medical Release

Participant Name: ________________________________________________________

Emergency Contacts:

Name: __________________________________________________________________

Relationship to Participant _________________________________________________

Contact Phone (_____)______________________

Name: __________________________________________________________________

Relationship to Participant _________________________________________________

Contact Phone (_____)______________________

Medical Insurance Co. _____________________________________________________

Phone (____)___________________________

Policy # _______________________________

Primary Care Physician: ____________________________________________________

Phone (____)___________________________

Special Medical Conditions (i.e. allergies, chronic illness, or other conditions):

________________________________________________________________________

Current Medications:

________________________________________________________________________

Anything else you need to tell us? (i.e. special needs, concerns, etc.):

________________________________________________________________________

Permission Slip And Medical Release Form Page 2