• Student liablity release and medical form
  
• Adult liability release and medical form
  
• Student and adult forms (French)
• Formularios para estudiantes y adultos (español)
• Información para padres de estudiantes (español)

• 2011 Annual Report
• 2010 Annual Report

MEDICAL RELEASE

Participant’s Name: ___________________________ Date of Birth/Gender: ______________

Parent/Guardian Name: ________________________ Program Dates: ___________________

School/Organization: ___________________________ Phone (Home): ___________________

(Cell): _____________________

Emergency Contact: ____________________________

Emergency Phone: _____________________________ Insurance Carrier: ________________

Alt. Emergency Ph: ____________________________ Policy Number: __________________

1. Is participant taking any medications? ..............................................................................Yes No

If yes, please list and describe:

2. Does participant have any allergies (e.g red ants, bees, food, medications)? ...................Yes No

If yes, please describe:

3. Does participant have any dietary restrictions (e.g. vegetarian, kosher etc.)? ..................Yes No

If yes, please describe:

4. Has the participant been directed to carry Epinephrine (e.g Epi Pen/Ana Kit)? ..............Yes No

If yes, will s/he have it while on the program? .........................................................Yes No

5. Are there any reason(s) to restrict full activity of participant? .........................................Yes No

6. Does participant have special needs to consider? (e.g. special medical conditions (asthma,

ADD), foreign language, disabilities, specific fears, previous injuries, etc.)?..........Yes No

If yes, please describe:

___________________________ ___________________________ ___________________

Signature of Participant Printed Name Date

___________________________ ___________________________ ___________________

Signature of Parent/Guardian Printed Name Date

(For participants under 18)