Medical Release Form

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MEDICAL RELEASE FORM
Student Name
School
It is understood that consent is given in advance of any emergency, diagnosis, or treatment required while the student is participating in
SkillsUSA activities and, that this Medical Release Form authorizes designated school personnel to exercise their best judgement should
action be warranted to ensure student's safety, life, and health. This form should be signed and will be kept with designated school
personnel during the SkillsUSA activities.
In the space provided, describe what should be done in case of an emergency when religious beliefs prohibit any emergency medical
attention for accident, sickness, or injury.
General Information
Allergies to food, medication, other
Specific Medical Problems _____________________________________________________________________________
Date of last tetanus________________________________________________________________________________
Physical handicaps or limitations______________________________________________________________________
Other (please be specific____________________________________________________________________________
If any medication is currently being taken, provide the following information
Name of medication(s)_____________________________________________________________________________
Prescribing Physician_______________________________________________________________________________
Physician's Office Telephone_____________________________ Physician's Home Telephone__________________
Medical Information (will be used only in case of an emergency)
Insurance Company Name________________________________
Name of Insured____________________________
Policy Number__________________________________________
Group Number______________________________
Should there be an emergency, contact
Person________________________________________________
Relationship________________________________
Work Telephone________________________________________
Home Telephone____________________________
Home Address_____________________________________________________________________________________
Employer and Address_______________________________________________________________________________
______ I hereby give permission for____________________________________to receive immediate medical treatment as required in
the judgement of the attending physician. Notify me and/or person(s) listed above as soon as possible.
______ I do not give permission for medical treatment until I have been contacted.
Signed___________________________________________________________Date_______________________________
C:\dexform\good_results\xml\nolinks\270795.xml

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