Youth Group Medical Release Form printable pdf download

St. Georges Youth Group Medical Release Form 2012- 2013

Name of Participant ____________________________ Date of Birth ___________________

Name(s) of Parent/Guardian _______________________________________________________

Address _______________________________________________________________________

City ___________________________________ State ___________ Zip ________________

Home Phone ____________________________ Work Phone __________________________

Person to be contacted in an emergency______________________________________________

Phone number(s) where parent/guardian/emergency contact can be reached _________________

_____________________________________________________________________________

Heath Insurance Carrier __________________________________________________________

Group (Employer) # ______________________ Policy # ______________________________

Check either of the following that may apply:

This insurance policy requires primary-care physician notification or pre-approval prior to

emergency treatment.

This insurance policy requires primary-care physician notification or pre-approval prior to

routine medical care.

Physician’s Name ________________________ Phone _______________________________

Dentist’s Name __________________________ Phone _______________________________

Please list significant medical history (major illnesses, surgery, injuries, etc.)

_____________________________________________________________________________

Please list all known allergies

_____________________________________________________________________________

Please list all medication participant is currently taking, both prescription and over-the-counter

_____________________________________________________________________________

MEDICAL RELEASE: In case of emergency, I/we, the parent(s) or guardian(s) of the above-

named participant, understand that every effort will be made to contact me/us. In the event that

I/we cannot be reached; I/we hereby give permission to the physician(s) and/or dentist(s) selected

by the St. Georges staff to hospitalize and secure proper treatment, including tests, x-rays,

anesthesia, and/or surgery, for the participant.

_____________________________________ _____________________________________

Mother or legal guardian

Date

Father or legal guardian

Date

Youth Group Medical Release Form