Liability Release Permission Form Page 2

ADVERTISEMENT

FFA CAMP MEDICAL INFORMATION
Physician’s Phone_______________
Emergency #_______________________
We need the following Medical History for your child should sickness or injury occur. Check and/or
give approximate dates where applicable:
Please use this side for further details or pertinent information.
Revised 04/01/2013
_
_____Frequent Colds
______Heart trouble
______AIDS (HIV virus)
______Frequent sore throats ______ Measles
______Hay fever/asthma
______Stomach Upsets
______German Measles
______Tetanus booster
______Abscessed ears
______ Mumps
______Insect allergies
______Bronchitis
______Chicken Pox
______Polio vaccine booster
______Fainting
______Rheumatic Fever
______Broken bones
______Constipation
______Diabetes
______Typhoid vacc booster
______Hepatitis
______Epilepsy
______Serious ivy poisoning
Has your child had any major surgery? (Circle One) Yes
No
If so, please describe on back.
Is your child allergic to penicillin? (Circle One)
Yes
No
Other drugs? _____________________________________________
Other allergies? ____________________________________________
Details___________________________________________________
Is your child taking medication/s at this time? (Circle One) Yes
No
Type/Dosage _____________________________________________
For What? ______________________________________________
Type/Dosage_____________________________________________
For What? ______________________________________________
Please Print
Father: _________________________ Phone-Day: ______________Eve______________
Mother: _________________________ Phone-Day: ______________Eve:______________
Legal Guardian: ___________________ Phone-Day: ______________Eve:______________
Person to contact in emergency if age 21:____________________PH:________________
Hospital Insurance (Circle)
Yes
No
Insurance Co________________________________
Policy #:______________________
Physician’s Name___________________________________________________________

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Medical Release Liability Release Permission Slip Form Medical Release Liability Release Permission Slip Form Legal
Parental Permission And Medical Consent With Liability Release Form Parental Permission And Medical Consent With Liability Release Form Legal
Trip Or Activity Liability Release Form With Permission To Search Belongings Trip Or Activity Liability Release Form With Permission To Search Belongings Legal
Field Trip Permission Form Release, Indemnification & Waiver Of Liability Field Trip Permission Form Release, Indemnification & Waiver Of Liability Education
Field Trip Permission Form - Release, Indemnification & Waiver Of Liability Field Trip Permission Form - Release, Indemnification & Waiver Of Liability Education
Volunteer Permission Release And Waiver Of Liability Form Volunteer Permission Release And Waiver Of Liability Form Legal
Medical Release & Permission Form Medical Release & Permission Form Legal
Child Comprehensive Medical Release & Permission Form Child Comprehensive Medical Release & Permission Form Legal
Equipment Rental And Liability Release Agreement Form Equipment Rental And Liability Release Agreement Form Legal
Release Of Liability Release Of Liability And Waiver Of Claims Release Of Liability Release Of Liability And Waiver Of Claims Legal

Related Categories

Parent category: Legal
Download
Go
Page of 2