2023 Leadership Summit Participant Medical Release Form
Friday, March 3, 2023
STUDENT INFORMATION
Sponsoring Cooperative
*
Alfalfa
Arkansas Valley
Canadian Valley
Central
Choctaw
Cimarron
CKenergy
Cookson Hills
Cotton
East Central
Golden Spread
Harmon
Indian
KAMO
Kay
Kiamichi
Lake Region
Northeast OK
Northfork
Northwestern
OAEC
Oklahoma
Ozarks
People’s
Red River Valley
Rural
Southeastern
Southwest Rural
TCEC
Verdigris Valley
Western Farmers
Other
Student Name
*
First Name
MI
Last Name
Student Date of Birth
*
-
Month
-
Day
Year
Date
Student Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Cell Phone Number
*
-
Area Code
Phone Number
Student Email
*
example@example.com
Back
Next
PARENT/GUARDIAN INFORMATION & RELEASE
Parent/Guardian #1
*
First Name
Last Name
Parent/Guardian #1 Email
*
example@example.com
Parent/Guardian #1 Phone Number
*
-
Area Code
Phone Number
Relationship to winner
*
Parent/Guardian #2
First Name
Last Name
Parent/Guardian #2 Email
example@example.com
Parent/Guardian #2 Phone Number
-
Area Code
Phone Number
Relationship to winner
Back
Next
MEDICAL INFORMATION & RELEASE
Current Medications
Medication
Dosage
Reason for taking
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
Medication #6
Medication #7
Medication #8
Additional Medication Information
Current Allergies
Allergy
Reaction/Action Needed
Allergy
#1
Allergy
#2
Allergy
#3
Allergy
#4
Allergy
#5
Allergy
#6
Allergy
#7
Allergy
#8
Additional Allergy Information
List all medical conditions or problems, which may require special care or attention
*
Physician & Insurance Information
Physician Name
*
First Name
Last Name
Physician Phone
*
-
Area Code
Phone Number
Name of family medical insurance company
*
Medical insurance policy holder name
*
Medical insurance policy number
*
*
I certify that I have answered the above questions as accurately as possible, and that all known medical information about this student has been listed accordingly and that I/we have read, understand and acknowledge that I/we are releasing OAEC and from any and all claims, causes of action and liability which may arise as a result of said medical conditions listed or should have been listed.
Parent/Guardian #1 Signature
*
Clear
Parent/Guardian #2 Signature
Clear
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: