Medical Release/history Form

ADVERTISEMENT

2016 HIGHER THINGS® CONFERENCES
Medical Release/History Form

Registrant Information
Child/Dependent’s Name
Date of Birth
Address
City
State
Zip
Home Phone
Cell Phone
Parent/Guardian Name
Email of parent/guardian
Work Phone
Cell phone
Physician’s Name
Physician’s Phone number
Emergency Contact
(if listed parent/guardian is unavailable)
Name
Relationship to Child
Phone
Address
City
State
Health History
Known Medical Problems:
Medications to be taken with directions:
Medication Allergies:
History of Asthma?
Y
N
History of seizures?
Y
N
History of heart problems?
Y
N
If yes, nature of problem:
May be given as necessary:
Last Tetanus shot (Td):
Tylenol
Y
N
Ibuprofen
Y
N
Health Insurance Company:
Group Number:
ID Number:
I hereby give my consent in advance to the designated leaders of ___________________________________________________ and
to the physicians or hospital selected by them to render emergency treatment as in their judgment is reasonably necessary, including,
but not limited to, hospitalization, diagnosis including taking specimens and x-rays, giving blood transfusions and medications,
anesthesia and surgery for my dependent listed above. I understand that the leaders of this activity will attempt to contact me before
securing medical treatment, but that this consent is given in case I am not available in an emergency.
I specifically release the leadership of this activity from any and all claims, loss, cost, damage or expense arising out of or from any
accident or other occurrences causing injury to any person or property.
Signature of Parent/Guardian
Date
Signature of non-related adult witness
Date
22

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go