• Medical Information and Release Form

    This form must be completed for all activities, Regional and National conferences annually.
    Medical Information and Release Form

  • Member Information

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  • Medical Information

    Instructions: Check all that apply. If a condition is checked, please provide details in the space provided.
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  • 8242 Sunbeam St. Granville, NY 12832 | www.yourcompany.com | (123) 456-789

  • Insurance and Physician Information

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  • Release Information

  • Medical Authorization

    I,as a parent or legal guardian, hereby give my consent for a chaperone or other adult representative to obtain such medical care as is reasonably necessary for the welfare of my child/teen, in the event of any emergency or other medical occurrence. I request that payment under my medical insurance program be made directly to the site of services rendered. I understand I am financially responsible for fees not covered by this authorization.

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  • General Release

    I,as a parent or legal guardian, hereby release from any and all liability which might result from any personal injury claims or cause of action which might result directly or indirectly from my minor child/teen’s participation in any activity or trip.

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  • Important Notice: In accordance to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule regulation, it is important that all parties in receipt of this form, assure that the information contained on this document is properly protected while allowing the flow of health information needed to provide health care and to protect the individual’s health and well being. The purpose of the Privacy Rule is to define and limitthe circumstances in which an individual’s Protected Health Information (PHI) may be used or disclosed. Contents contained on this document should only be discussed or shared with the individual (or their personal representative) or for the treatment activities of any healthcare provider.

  • 8242 Sunbeam St. Granville, NY 12832 | www.yourcompany.com | (123) 456-789

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