Youth Medical Release Form printable pdf download

EXETER PARKS & RECREATION

Please return to:

MEDICAL RELEASE FORM

Exeter Parks & Recreation

Department

32 Court St.

Exeter, NH 03833

Phone: 773-6151

Fax: 773-6152

I, ____________________________________ (Parent/Guardian's Name) hereby give permission for Exeter Parks & Recreation

Department of 32 Court St. Exeter, NH to consent to in my absence and absence of other legal guardian, any and all medical

attention to be administered to my child __________________________________ (Child's Name) In the event of accident, injury,

sickness,etc., under the direction of a recognized medical facility, under the general or special supervision of a licensed physician

or surgeon until such time as I may be contacted. I also assume the responsibility for the payment of any such treatment.

SIGNATURE OF PARENT____________________________________________DATE:___________________________

Child’s name:

Age:

D.O.B.

_________________________________________________________________________________________________________

Home Phone:

Work/Cell/Pager number:

_________________________________________________________________________________________________________

Home address:

Work location:

_________________________________________________________________________________________________________

In case I cannot be reached, the following person/persons is/are designated to act on my behalf.

Name: __________________________________relationship:_______________________________________________________

Home Number: ___________________________________Cell/Pager Number: ________________________________________

PHYSICIAN:

___________________________________PHONE: _________________________________________________

ADDRESS:

___________________________________________________________________________________________

KNOWN ALLERGIES:

_____________________________________________________________________________________

IF ALLERGY, WHAT IS THE REACTION? ______________________________________________________________________

THE TREATMENT FOR ALLERGY EXPOSURE? _________________________________________________________________

MEDICATIONS: ___________________________________________________________________________________________

TETANUS (DATE GIVEN): ____________________

ANY OTHER INFORMATION STAFF/VOLUNTEER OF EXETER PARKS & RECREATION DEPARTMENT SHOULD BE MADE AWARE OF?

(MEDICAL, FAMILY, DEVELOPMENTAL)

Note: If you need to provide more information than space allows please use the back of this form or attach a separate sheet and indicate that

there is more “over” or “attached”

Note: Due to the fact that we do NOT keep your child’s medical form on file here at the Recreation Department we require you to

fill this form out BEFORE the start of the program.

Thank you for completing this form, it will be in the possession of your child’s coach/staff member in the event of an emergency.

Youth Medical Release Form

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