Академический Документы
Профессиональный Документы
Культура Документы
I, Participant's Parent/Guardian further state that I am fully competent to sign this Agreement; and that I execute
this release for full, adequate, and complete consideration fully intending for myself, for the Participant, and for
Participant's family, estate, heirs, administrators, personal representatives, or assigns to be bound by the same.
IN WITNESS WHEREOF, we have executed this release this
day of
STUDENT/PARTICIPANT
(Signature)
(Signature)
, 200 _.
MEDICAL INFORMATION
EVERY PARTICIPANT MUST HAVE THIS COMPLETED FORM ON FILE
Participant Name
Indicate medication(s) that are taken on a regular basis. Note that participant should bring an
adequate supply of all medication(s) with them.
Name of Medication
Dosage
Name of Medication
Dosage
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Heart Disease
Phobias or Fears
Past Injuries/Illnesses
Past Operations
Other
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
If you answered yes for any of the above conditions, please explain in detail. Use a separate
page if necessary.
Date
Parent/Guardian Signature
Date
Street
City
State
Zip Code
Date of Birth
Effective Date
Group #
Policyholders Name
Policy #
Policyholders Address
Street
City
State
Zip Code
Relationship to Participant
Contact #
Employee Number
I hereby authorize the release of any medical information that might be needed in connection with
payment for medical services.
Participant Signature
Date
Parent/Guardian Signature
Date
I request that payment under my medical insurance program be made directly to the provider on
any bills for services rendered by that provider. I understand that I am financially responsible for
fees not covered by this authorization.
Participant Signature
Date
Parent/Guardian Signature
Date
EMERGENCY INFORMATION
EVERY PARTICIPANT MUST HAVE THIS COMPLETED FORM ON FILE
Participant Name
Participants Address
Street
City
State
Date of Birth
Relationship
Address
Day Phone
Evening
Name
Cell Phone
Relationship
Address
Day Phone
Evening
Name
Cell Phone
Relationship
Address
Day Phone
Evening
Cell Phone
Zip Code