Medical Release


Click here for printable PDF version of the Medical Release Form

Click here for printable PDF version of A+ Hold Harmless Agreement

Click here for printable PDF version of Main Trip Hold Harmless Agreement

MEDICAL INFORMATION

 

Name___________________________________ Home phone:(_____)___________________

Cell phone(s)_________________________________________________________________

Address_____________________________________________________________________

D.O.B.___________ Age_____ Parent’s work phone:(_____)___________________________

Parent(s) name(s)________________________________ email:________________________

Emergency contact/Neighbor___________________________ phone:(_____)______________

Recent surgery/illness____________________________________________ Date__________

Asthma/other limiting conditions__________________________________________________

Any known allergy to medication__________________________________________________

Childhood diseases_____________________________________________________________

Date of last tetanus shot__________ Home physician_________________________________

Address__________________________________________ phone:(_____)_______________

Medication to be taken/dosage___________________________________________________

for the following condition_______________________________________________________

**Major medical insurance carrier_________________________________________________

Insurance billing address________________________________________________________

Subscriber name______________________________________________________________

Subscriber employer & policy #___________________________________________________

**Each participant must provide their own major medical coverage. There is no medical

  coverage provided as part of this program.

Please note: Please read & sign indemnification agreement on the back.

AUTHORIZATION FOR MEDICAL TREATMENT: I hereby authorize that medical and/or surgical care be provided for my child. I assume all financial responsibility for this care.

Signature_________________________________ Relationship___________ Date__________

Guardian (Please Print)____________________________________________________________

Additional information__________________________________________________________

 

REMINDERS: Are there any blank spaces on this form? Please complete.

A parent must sign front & back if you are under 18

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