MADE for MORE 2017 Medical Release

MADE FOR MORE 2017 | Medical Release

Medical Information

Please Print Participant Name: ______Address:______City:______State:____ZIP:______

Do you have medical insurance: Yes:__ No:__ If so, name of company: ______Policy Number:______Name of Primary person insured:______

Circle communicable diseases participant has had: Measles Polio Mumps Chicken Pox Scarlet Fever Whooping Cough

When did participant receive the following immunizations: ___Polio ___Diphtheria ___Whooping Cough ___Tetanus Toxoid

Does participant have? (circle all that apply) Diabetes Asthma Heart Trouble Ear Trouble Hernia Skin Trouble Lung Trouble Allergies HIV/AIDS

Name Allergies or medications participant is allergic to:______Has participant been under medical care within the last 3 months: Yes:____No:____ If yes then, for what reason? ______Is the participant currently under medical treatment? Yes:___No:___ If yes then, for what reason? ______

Check if participant may be given the following: __Tylenol __Ibuprofen __Benadryl __Aspirin

Participant must be fever free for 24 hours before allowed to attend the event. This is for the safety of all children. Early Departure Policy: Only an authorized person designated on the registration form may remove a student from the event. Please list authorized person(s):______

Emergency Treatment Permission

I (parent/guardian) do hereby state that I have legal custody of this child, a minor, who resides with me. While this minor is a registered participant on the 2017 Georgia Made for More Conference at Timberlake Retreat Center, I hereby authorize any director, counselor, nurse, lifeguard, or other responsible personnel of said event to consent to any x-ray, examination, anesthetic, medical or surgical treatment and hospital care, to be rendered to this minor under the general or special supervision and advice of any physician or surgeon licensed to practice in the state of Georgia when such medical or surgical treatment is necessary.

Activities Release I/We have read the rules pertaining to this event and agree to abide by them. I (parent/guardian) do hereby give permission for the participant registered in this application to participate in all event activities.

Parent/Guardian Signature:______Date:______Participant Signature:______Date:______