2020-2021: Adult Participation Form

2020-2021: Adult Participation Form

Term: June, 2020 - May 31, 2021
Event Name
Personal Information
Participant Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Preferred Phone Number *
Home Mobile
Preferred Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State

Zip Code
Allergies or Medical Conditions: *
Preferred Emergency Contact Information
Name *

First Name Last Name
Relationship *
Phone Number *
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State

Zip Code
Secondary Emergency Contact Information

In the case the Primary Emergency contact cannot be reached
Name *

First Name Last Name
Relationship *
Phone Number *
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State

Zip Code
Permissions
Signature *

Clear
AUTHORIZATION TO CONSENT TO MEDICAL TREATMENT:

The undersigned consents:

1. The administration of any treatment deemed necessary by:
Preferred Physician
Preferred Physician's Phone Number
Preferred Dentist
Preferred Dentist Phone Number
OR in the event the appropriate specified practitioner is NOT available, by licenced physician or dentist:

2. The transfer of participant to preferred hospital or any hospital reasonably accessible.
Preferred Hospital *
3. This authorization does not cover major surgery unless the medical opinions of
two other licensed physicans or dentists concurring in the necessity for such surgery are obtained in writing prior to the performance of such surgery.
Medical Insurance Carrier *
Policy Number *
I AGREE *
Initial Here
Date

Month Day Year
Date
PRINT NAME *

First Name Last Name
Signature *

Clear
Should be Empty:

2020-2021: Adult Participation Form

Personal Information

Preferred Emergency Contact Information

Secondary Emergency Contact Information

Permissions