Parent/guardian Consent-Medical Release And Release From Liability Agreement Form (Page 2 of 4) in pdf

HEALTH INSURANCE INFORMATION SHEET

EVERY PARTICIPANT MUST HAVE THIS FORM ON FILE

Private insurance information must be provided, if applicable. Please be advised that, should a participant require medical

attention, you are responsible for paying any costs not covered by insurance.

Participant Name ______________________________________________________________________________

Participant’s Address ___________________________________________________________________________

Participant’s Phone Number ___________________

Date of Birth _______________________________

Insurance Company Name _______________________________ Effective Date ___________________________

Address of Insurance Company ____________________________________________________________________

Phone Number of Insurance Company ________________________________ Group #_______________________

Policyholder’s Name __________________________________ Policy #___________________________________

Policyholder’s Address __________________________________________________________________________

____________________________________________________________

Relationship to Participant

Contract #______________________________________ Employee Number _____________________________

I hereby authorize the release of any medical information which might be needed in connection with payment for

medical services.

Parent/Guardian Signature

Date __________________

Parent/Guardian Signature

Date __________________

I request that payment under my medical insurance program be made directly to the provider on any bills for

services rendered by that provider. I understand that I am financially responsible for all costs not paid by my

medical insurance program.

Parent/Guardian Signature

Date __________________

Parent/Guardian Signature

Date __________________

EMERGENCY INFORMATION AND CONTACTS

Please complete this form in its entirety. This information will be helpful in the unlikely event of an accident or

sudden illness.

Name of Personal Physician ___________________________________________ Phone _______________________

Physician Address _______________________________________________________________________________

Person(s) to be contacted in case of Emergency:

Name ____________________________ Relationship_____________________________

Address _______________________________________________________________

Daytime Phone _________________________ Evening Phone_________________ Cell Phone______________

Name ____________________________ Relationship_____________________________

Address _______________________________________________________________

Daytime Phone __________________________ Evening Phone________________ Cell Phone______________

C:\Documents and Settings\robertm\Desktop\Medical Forms Revised 120308.doc

Parent/guardian Consent-Medical Release And Release From Liability Agreement Form Page 2