Adult Permission, Release And Medical Power Of Attorney Form (Page 2 of 2) in pdf

Adult Permission, Release And Medical Power Of Attorney Form Page 2

Medical Information —Please Print

Name ________________________________________________________ Birth date ______/ _____/ ______

Soc. Sec. # *_______________________________

Allergies ___________________________________________________________________________________

Medications ________________________________________________________________________________

Chronic Conditions (e.g. epilepsy, diabetes) _______________________________________________________

Medical Insurance Co. _______________________________________ Policy No. _______________________

Member’s Name ____________________________________ Phone: (h) ______________ (w) _____________

Member’s Birth date ______/ _____/ ______ Member’s Soc. Sec. # *__________________________________

Family Doctor ______________________________________ Phone __________________________________

* Social Security number is optional. Please note that some hospitals WILL NOT treat without it.

ACTIVITY INFORMATION FORM

Completed by Organizer - Please Print

Organizer

Activity

Location

Emergency No.

Cost

Starting Date and Time

Meeting Place

Ending Date and Time

Meeting Place

Activities Involved

Type of Transportation (if any)

Group Leader

Telephone No.

Other Information

_____ Check here if any additional information is attached.

Adult Permission, Release And Medical Power Of Attorney Form Page 2