Medical Release Form
For 2005 Bym Annual Session

James Madison University

08/1 - 7/2005

Children under 18 years old must have the Medical History and Medical Release Forms completed to participate in any of the children’s programs.

 

I give the Baltimore Yearly Meeting staff and its volunteers permission to obtain emergency help for me or my child(ren) named on this form and I hereby release the Baltimore Yearly Meeting, its staff, and volunteers from liability for any injury or illness that I or my child(ren) may sustain during the 2005 Annual Session. I will be responsible for costs incurred for any medical treatment. In the event that I or my child(ren) need(s) special medications and cannot administer them, I give my permission for an adult staff or volunteer to administer the medications. (Each child must have a separate form)

Child’s Name: _______________________________________________________________________________

Parent’s Signature: __________________________________________________ Date: __________________

Print Parent’s Name: __________________________________________________________

EMERGENCY CONTACTS:

Name: ________________________________________________ Phone: ______________________

Name: ________________________________________________ Phone: ______________________

 

Medical History and Information

Present Medications: _______________________________________________________________________________

Medical History (if relevant): ________________________________________________________________________

Food or Drug Allergies: _____________________________________________________________________________

Date of Last Tetanus Shot: ______________________ Insurance Co.: ___________________________________

Policyholder’s Name: __________________________ Policyholder’s DOB: ______________________________

Policy #: ______________________________________ If an HMO, Phone #: ______________________________

Family Doctor: ________________________________ Phone: _________________________________________

 

Letter of Understanding (For Young Friends Only)

We have read the Letter of Understanding, agree with the sense of our responsibilities, and agree to these responsibilities.

Sign and Print Name and Date:

Young Friend ___________________________________________________ ___________________________

Parent/Guardian: _______________________________________________ ___________________________

Sponsor: _______________________________________________________ ___________________________