NOTE: Sample health form that can be adapted for use by local advisors
_____________________ FAMILY, CAREER & COMMUNITY LEADERS OF AMERICA
(local chapter name)
Medical Release Form
I, _________________________________________________ of ______________________________________________________
Parent/Guardian Name
Address
__________________________________________________ am the __________________ of______________________________
City
State
ZIP
Relation
Member’s Name
of_________________________________________________ .
City
State
ZIP
I hereby give my consent, in the event all reasonable attempts to contact me have been unsuccessful, for immediate medical treatment as
required in the judgment of the attending physician while _________________________________________________ is absent from
home ___________________to __________________.
date
date
Member's Date of Birth: _________________________________ Social Security Number (optional): __________________________
Parent/Guardian Phone Number(s):Work:(____)______________________________ (____) ________________________________
Home:(____) _____________________________ (____) ________________________________
Family Physician: ______________________________________ Family Dentist: _________________________________________
Address: ___________________________________________
_________________________________________
Street
Street
_____________________________________________
__________________________________________
City
State
ZIP
City
State
ZIP
Phone:(____) _________________ (____) _________________
(____) ______________ (____) _______________
Work
Home
Work
Home
Medical Insurance Company __________________________________ Policy Number: ____________________________________
Name of Insured: ______________________________________________________________________________________
The following information is needed by any hospital or practitioner not having access to a medical history:
Allergies: ___________________________________________________________________________________________________
Medication being taken: ________________________________________________________________________________________
Date of last tetanus shot:________________________________________________________________________________________
Physical impairments:__________________________________________________________________________________________
Other pertinent facts to which physician should be alerted: _____________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
(over)