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2013 Medical Release Form

This form MUST be completed and submitted
I. STUDENT INFORMATION
Student Name: __________________________________________________ DOB: ___ / ___ / ______
Address: _____________________________________________________________________________
City: _______________ ________
State: ______________________
Zip Code: ___________
Email: ________________________________________________ Cell Phone: ____________________
Parent / Guardians Name: ______________________ Relationship to Student: __________________
Home Phone: (____) __________
Work Phone: (____) __________ Cell Phone: (____) __________
Secondary Contact to notify in case of emergency: ____________________________________________
His / Her relationship to you: ______________________________ Phone Number: (____) __________
II. MEDICAL INFORMATION
Please supply ALL of the information. If you DO NOT have an insurance policy, please check the box
below. If you do have insurance, please attach a COPY of your Insurance Card.
I DO NOT HAVE HEALTH INSURANCE
Medical Insurance Company: ____________________ Group #: __________ Policy #: ___________
Companys Address: _________________________________
Companys Phone: (____) __________
Physicians Name: ________________________________________ Phone Number: (____) __________
Physical Limitations (Asthma, Diabetes, ALLERGIES, etc.), and/or Special Instructions
(Allergic to Certain Medications, Rare Blood Type, Wears Contact Lenses, etc.)
_____________________________________________________________________________________
_____________________________________________________________________________________
List ALL medications taken on a regular basis and / or brought with you during the activity:
_____________________________________________________________________________________
_____________________________________________________________________________________
List ALL operations and / or serious injuries and dates that have occurred within the past 5 years:
_____________________________________________________________________________________
_____________________________________________________________________________________
Date of Last Tetanus Shot: _______________________________________________________________
The Health History is correct as far as I know, and the person herein described has permissions to
engage in all prescribed activities as noted.

The Korean Youth Center of New York 2013

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III. Authorization & Release

EMERGENCY AUTHORIZATION:
I hereby grant permission to the medical personnel selected by the Korean Youth Center of New York /
the designee (staff member) or event coordinator to order X-rays, routine tests, and treatment for my
child. In the event of an emergency, and neither the secondary contact nor myself can be reached, I
hereby give permission to the medical personnel selected by the Korean Youth Center of New York or
designee to hospitalize, secure proper treatment, order injections and / or anesthesia and / or surgery
for my child as named above. I further authorize the release of the above medical information to the
appropriate medical personnel and / or the health coverage insurance company.
In addition, I have, and do hereby, release THE KOREAN YOUTH CENTER OF NEW YORK, its pastors,
employees or agents from liability associated with participation in any of the Korean Youth Center of
New Yorks activities for one year from the date of signature & notarization below.

PHOTO RELEASE:
This document serves as a release for my child(ren) to appear in photographs and / or videotapes while
participating in the Korean Youth Center of New Yorks activities for the purpose of the organization
including, but not limited to, the organizations website, staff training and / or promotion.

________________________________________________
Signature of Parent or Legal Guardian

___________________
Date

I _____________________________________, understand and agree to abide with the restrictions

placed on my activities by my parent / guardian.

________________________________________________
Signature of Participant

___________________
Date

The Following shall be completed by the notary witnessing the parent / guardians signature:
The State of ____________________________ the county of ____________________________
Before me, a Notary Public, on this day personally appeared _______________________ known to
me (or provided to me on the oath of ___________________________________) to be the person
whose name is subscribed to the foregoing instrument acknowledged to me that he / she executed
the same for the purpose and consideration therein expressed. Given under my hand and the seal
of the office this _______ day of _____________, A.D. __________________.
____________________________________________________ Notary, State of
_______________________________________ Print name of Notary Public Here My commission
expires on the ________ day of _______________, A.D. __________________.

The Korean Youth Center of New York 2013