Medical Release & Permission Form printable pdf download

Medical Release & Permission Form

2015-2016

Medical Release & Permission Form

Page 1 of 2

Please Print in ink

Name ________________________________________________ Age ________ Birthday ______________

AST

IRST

IDDLE

 Male  Female

Year in school

E-mail_______________________________________

Address

City

State

Zip

Primary Phone (Cell or Home) _______________________ Secondary Phone (Cell or Home)___________________

Parent 1 name

Cell or Home

Work

Parent 2 name

Cell or Home

Work

Emergency contact

Cell or Home

Work

Other than Parents listed above. Parent will be contacted first. If unable to contact them, please indicate who to contact.

Medical Insurance Company_________________________ Policy Number__________________________________

Physician ________________________________________ Office phone __________________________________

Medical History

Check the following areas of concern for this youth. If necessary, add another page with details.

1. Does your youth have allergies to

 pollens

 medications

 food

 insect bites

If any of the above are checked, what are the symptoms?_________________________________________

What is the medication/treatment?____________________________________________________________

2. Does your youth experience any of the following or is currently being treated for any of the following:

 epilepsy/seizure disorder

 heart trouble

 diabetes

 Other _______________

 frequently upset stomach

 ADHD/ADD

 physical handicap

______________________

If any of the above are checked, what is the treatment?___________________________________________

What is the medication?____________________________________________________________________

 Yes

 No

3. Does your child suffer from asthma?

If you checked yes above, what is the treatment?_________________________________________________

 No

Does child use a rescue inhaler? Yes

If you child uses a rescue inhaler, they will be required to have the inhaler at MUMC Youth Group activities.

 glasses

 contact lenses

4. Does your youth wear

5. For your youth’s safety and our knowledge, is your youth a

 good swimmer

 fair swimmer

 non-swimmer

Any other information?

Medical Release & Permission Form

Related Articles

Related forms

Related Categories