Parent /guardian Consent And Emergency Medical Release Form
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2PARENT /GUARDIAN CONSENT AND EMERGENCY MEDICAL RELEASE FORM
Name of the Event:
___________________________________________________________________________________
Destination:
___________________________________________________________________________________
Designated Supervisor of Activity:
___________________________________________________________________________________
Date and Anticipated Time of Departure: ___________________Return: ____________________
Cost to Youth: ______________
Method of Transportation:
_________________________________________________________________________________________
Name of Youth:
________________________________________________________________________________
Date of Birth________________________
Grade_________
Gender: Male____ Female ____ (check one)
Home Address:______________________________________________________________________________
Parent / Guardian's Name:__________________________________________________________________
Home phone:__________________ Work phone:___________________ Cell phone:____________________
MEDICAL INFORMATION
Please list all information pertaining to allergies, diet, special medications, health conditions or any other
information necessary in an emergency situation.
Explain fully:________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Medications: My child is taking the following medication(s):
Description ___________________________________________ Dosage _______________________________
Description ___________________________________________ Dosage _______________________________
Medical / Hospital Insurance
Carrier:____________________________________________________________________________________
Name of Policy Holder ________________________________ Relation to participant ____________________
Policy Number: _________________________________ Group Number: ______________________________
Revised 03/2010
Parent / Guardian Consent and Emergency Medical Release Form
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Parent category: Legal