Patient Medical Form (Page 2 of 2) in pdf

In case of emergency during the activity, notify:

Name:

Relationship: _____________________________________ E-Mail Address

Street address

City

State_____ Zip

(

)

(

)

(

)

Area Code

Day Phone

Area Code

Evening Phone

Area Code

Pager/Mobile

If person named above is not available in the event of an emergency, notify:

__________________________________ _________________ _____________________

Name

Relationship

Telephone

E-Mail Address

__________________________________ _________________ _____________________

Name

Relationship

Telephone

E-Mail Address

In case of emergency, I understand every effort will be made to contact me (if participant is an adult, my spouse or next of kin). In the event I cannot be

reached, I hereby give my permission to the licensed health-care practitioner selected by the adult leader in charge to secure proper treatment,

including hospitalization, anesthesia, surgery, or injections of medication for my child (or for me, if an adult).

Signature of parent/guardian

Date

(To be completed by all adult and youth participants)

STATEMENT OF UNDERSTANDING and SIGNATURES

I understand the importance of providing accurate medical information, and I

In the event of illness or injury occurring to me or to my son/daughter (if

certify to the accuracy of the foregoing information and that I am in good

applicant is younger than 18) during attendance at the conference, I do

health and know of no personal physical limitations that would prevent my full

hereby consent to whatever X-ray examination, anesthesia, medical or

participation in the conference (unless noted).

surgical diagnostic procedure, or treatment is considered reasonable and

necessary in the best judgment of the attending licensed physician and

I understand that this application includes my request for other personal

performed by or under the supervision of a member of the medical staff of the

accident insurance to be purchased on my behalf, and the cost of this

hospital furnishing medical services.

insurance is included in the registration fee.

I understand that in the event of a serious illness or injury, reasonable efforts

As an Adult Leader I will follow activity requirements for participation or as a

to notify those listed in case of emergency will be attempted.

youth participant, I will be responsible to my Adult Leader.

Does your group/post currently have accident and sickness insurance on adults and your participants? Yes ____ No ____

Insurer:

Policy expiration date

Policy No.

Signature of participant

Date

Signature of parent or guardian

(Required if participant is younger than 18)

Signature of Adult Leader*

Group/Post No.

LFL No.

________

Overnight Activities: All leaders must be registered as an adult with Learning for Life and provide male leaders for male youth participants and female leaders for

female youth participants.

REQUIRED FOR PARTICIPATION IN A CAMPING EXPERIENCE: COMPLETE THE PHYSICIAN’S OR

LICENSED HEALTH-CARE PRACTITIONER’S EVALUATION.

PHYSICIAN’S OR LICENSED HEALTH-CARE PRACTITIONER’S EVALUATION

Approved for participation in:

Hiking and camping

Competitive sports

Water activities

All activities

Specify exceptions ________________________________________________________________________________

Recommendations (explain any restrictions OR limitations): ________________________________________________

________________________________________________________________________________________________

Signed by Physician or Licensed health-care practitioner*____________________________________Date___________

Examinations conducted by licensed health-care practitioners other than physicians will be recognized for Learning for Life purposes in those states where such

practitioners may perform physical examinations within their legally prescribed scope of practice.

Patient Medical Form Page 2

Related Articles

Related forms

Related Categories