Shining Stars Medical Information & Release Form

Participant Name*

First NameLast Name

Parent/Guardian*

First NameLast Name

Email*

example@example.com

Phone Number*

Area CodePhone Number

Please list any medical/health problems that we should know about during Shining Stars activities:*

Mark N/A if there are none

Family Physician*

First NameLast Name

Physician Phone*

Area CodePhone Number

SHINING STAR ALLERGIES

Drug Allergies

Food Allergies

Other Allergies

PARTICIPANT MEDICATIONS

Please provide the name and dosage for any medications the participant will be taking during Shining Star activities.

ALL MEDICATIONS MUST BE IN THEIR ORIGINAL CONTAINERS

Name of Medication & Dosage (If none, please put NA)*

Name of Medication & Dosage

Date of last Tetanus (DT) injection*

Date

PERMISSION FOR TREATMENT

I, {parent/guardianName}, make oath and say that I am the lawful parent/guardian of the child listed herein and there are no court orders in effect that would prohibit me from conferring the power to consent upon another person.

I, hereby give my permission for the {participantName} to receive emergency medical or surgical treatment and hospitalization if necessary. I understand that every attempt will be made to contact me, or the emergency contact named below, before taking this action. However, if I or the contact listed below is unreachable I give my permission for immediate medical intervention. I will be financially responsible for any medical attention needed during the time {participantName} is participating in Miss Oregon's Shining Stars activities. My medical insurance shall be the insurance coverage for any medical treatment. I further agree that {participantName} may receive prescription medication only as prescribed during the time they are participating in Miss Oregon's Shining Stars activities. No over-the-counter remedies shall be administered at any time.

Name of 1st Emergency Contact (Please list someone who will be in Seaside during the Shining Star activities.)*

First NameLast Name

Relationship of 1st Emergency Contact*

Phone of 1st Emergency Contact*

Area CodePhone Number

Name of 2nd Emergency Contact

First NameLast Name

Relationship of 2nd Emergency Contact

Phone of 2nd Emergency Contact

Area CodePhone Number

Parent/Guardian Signature

Date