General Medical Release Form (Adult)
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1GENERAL MEDICAL RELEASE FORM
(Adult)
Participant’s Name _______________________________________ Birth Date ___________
Address _____________________________________ City and State _____________________
Home Phone _________________________________ Emergency Phone __________________
Allergies, medications, hay fever, insect bites, asthma, food, other ________________________
_____________________________________________________________________________
Other pertinent health history information: ___________________________________________
______________________________________________________________________________
Do you have any conditions that would prevent you from fully participating in this program? If yes,
please explain (specific activities/food to avoid)
______________________________________________________________________________
List any medications that are taken on a regular basis.
______________________________________________________________________________
Doctor _______________________________ Phone ____________________
Dentist_______________________________ Phone ____________________
Eye Doctor____________________________ Phone ____________________
Hospital_____________________________________ Phone ____________________
Medical Insurance Provider_________________________________
Group number: ________________________Policy #_____________________
Phone: _________________
EMERGENCY MEDICAL AUTHORIZATION
I give my consent for emergency medical treatment by a certified first aid person. In the event that
additional treatment is needed, the staff of the Emergency Room of the hospital listed above, or one
closest to the event location has my permission to administer treatment.
Signature ________________________________ Date __________________
Address ______________________________________________________________________
City ________________________________ State ___________________ Zip ____________
Phone home __________________________ (Work) ______________________
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Parent category: Business