DOF Youth Participation Form

DESERT OF FLORIDA

DESERT CONFERENCE / GALA DAY
PARTICIPATION AND MEDICAL AUTHORIZATION FORM
Please print or type. Note: This PDF form is fillable.
Date
Convention City
Temple/Court Name
Temple/Court City
Youth’s Name
Date of Birth

MonthDayYear
Date
Gender
Address

Youth Street Address

Street Address Line 2

CityState

Zip
Parent/Guardian Name
Phone
Format: (000) 000-0000.
Address if different than youth
Physician Name
Physician Phone
Format: (000) 000-0000.
Dentist Name
Dentist Phone
Format: (000) 000-0000.
MEDICAL HISTORY
1. Has this youth ever had hospitalizations, injury, or serious medical illness?
2. Is this youth now under the care of a physician or taking any medication?
3. Has any physician ever recommended, or do you feel that there should be limits placed on participation in competitive sports?
4. Does this youth have any known allergies to medication?
5. Does this youth wear glasses or contact lenses?
5.2 Give date of last exam, if glasses or contacts are worn

MonthDayYear
Date
6. Has this youth ever blacked out or lost consciousness during physical activity?
7. Has the child had a physical examination by a medical provider in the last six months?
7.2 If yes, list the of last physical examination

MonthDayYear
Date
7.3 If Yes to any of the above, please specify
8. Allergies/Special Health Considerations
PHOTO RELEASE
I consent to the participation of the above-named youth in the activities and conferences of His/Her youth group, including practice sessions and travel to and from athletics and other activities. I also agree to emergency medical treatment as deemed necessary by the physicians designated by the proper authorities.
Youth Name
Parent/Gaurdian Signature
Sign Date
Email Address
example@example.com
Leader's Email
Send a copy to the Youth Leader
Should be Empty:

PARTICIPATION AND MEDICAL AUTHORIZATION FORM

MEDICAL HISTORY