Permission and Medical Release Form
Permission and Medical Release Form
Please fill out this form with accurate and complete details.
Participant Information
Name
Date of Birth
Phone number
Address
Parent/Guardian Information
Name
Phone number
Medical Information
Does the participant have any allergies (food, medication, or environmental)?
If yes, please specify
Does the participant have any medical conditions we should be aware of?
If yes, please specify
Is the participant currently taking any medications?
If yes, please list medications and dosage
Has the participant had any surgeries/hospitalizations in the past 12 months?
If yes, please specify
Does the participant have any physical limitations or restrictions?
If yes, please describe
Additional Information
Consent and Release
I, the undersigned, hereby grant permission for my child to participate in the program hosted by [Your Company Name]. I understand that while all reasonable precautions will be taken to ensure the safety of participants, I release [Your Company Name] from liability for any injuries or damages that may occur. I authorize medical treatment to be provided to my child in the event of an emergency and understand that I will be responsible for any associated costs.
I further acknowledge and agree that this permission and medical release form may be signed electronically, and that such electronic signature will be treated as if it were an original signature, carrying the same legal weight and effect. By signing below, I confirm that I have read, understood, and accept the terms of this release.
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Participant
Name: Date: |
Parent/Guardian
Name: Date: |
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