MEDICAL RELEASE FORM

MEDICAL RELEASE FORM
Participant 1 Legal Name(s):
DOB(s):

MonthDayYear
Date
Participant 2 Legal Name(s):
DOB(s):

MonthDayYear
Date
Parent/Guardian(s):
Address:
Cell Phone:
Format: (000) 000-0000.
Email:
example@example.com
IF A PARENT/GUARDIAN CANNOT BE REACHED, PROVIDE AN ADDITIONAL CONTACT IN CASE OF EMERGENCY
Name:
Relationship:
Cell Phone:
Format: (000) 000-0000.
Name:
Relationship:
Cell Phone:
Format: (000) 000-0000.
MEDICAL INFORMATION
First Name:
Special needs or allegies:

YESNO
Required medication or food:

YESNO
Specify:
First Name:
Special needs or allegies:

YESNO
Required medication or food:

YESNO
Specify:
INSURANCE INFORMATION
Health Insurance Company:
Policy ID#:
Full name of Primary Insured:
Group ID#:
DOB of Primary Insured:

MonthDayYear
Date
Customer Service # on card:
PERMISSION, CONSENT, AND RELEASE
I hereby attest that all the information on this form concerning my dependent(s) is the most current available for my child(ren) (the Participant). I give my permission for the Participant to participate in the activities of Arts for All and Alamo Heights UMC. This includes all sponsored activities on or off the premises of Arts for All and Alamo Heights UMC, including all activities involving travel and/or lodging. This permission shall remain in effect for one year unless terminated in writing. I hereby authorize Arts for All and Alamo Heights UMC staff to administer the medications as listed on this form. In case of illness or injury, I hereby consent to and authorize the Arts for All and Alamo Heights UMC staff to obtain and consent to medical treatment by a medical clinic or hospital for such illness or injury during the activity or activities of Arts for All and Alamo Heights UMC. It is understood that this authorization and consent is given in advance of the Participant, in my absence, and medical staff to exercise their best judgment as to the requirements of such diagnosis or said medical treatment. I understand that all medical expenses incurred are my responsibility. This medical consent will remain in effect for one year unless terminated in writing. In consideration of Arts for All and Alamo Heights UMC allowing my child to participate in activities referenced above, I agree to release and hold harmless Arts for All and Alamo Heights UMC, its officers, agents and/or designated leadership, from any liability to or responsibility for bodily injury, damage or illness to my child while participating in any activity which may be directly or indirectly sponsored by Arts for All and Alamo Heights UMC. Further, I agree to indemnify and hold harmless Arts for All and Alamo Heights UMC, its officers, agents, and/or designated leadership with respect to any claim asserted by or on behalf of my child as a result of bodily injury, illness, or damage.
I HAVE READ AND UNDERSTAND THE ABOVE MEDICAL RELEASE.
Signature:
Date:

MonthDayYear
Date
Should be Empty:

MEDICAL RELEASE FORM

IF A PARENT/GUARDIAN CANNOT BE REACHED, PROVIDE AN ADDITIONAL CONTACT IN CASE OF EMERGENCY

MEDICAL INFORMATION

INSURANCE INFORMATION

PERMISSION, CONSENT, AND RELEASE

I HAVE READ AND UNDERSTAND THE ABOVE MEDICAL RELEASE.