Brighton FFA Medical Release Form

Brighton FFA Medical Release Form (please type or print clearly)

Name:______County:______

Male____ Female_____ 9th__ 10th__ 11th__ 12th__

Home Address:______

Insurance Company: ______Policy#______Expiration Date:______

Do you have any of the following: Severe Allergies (list): ______Severe Reactions (ex. Bee stings)______

Heart Condition____ Diabetes_____ Asthma______Epilepsy____

Other Contagious Condition______

Will you be taking any medications while on this trip?____ If yes, please list. 1.______4.______2.______5.______3.______6.______

Are there any other medical conditions that might affect you this trip? ______

Permission is hereby granted for ______to attend various FFA activities throughout the year and to receive the usual services of a registered nurse and/or physician in case of illness or injury. This includes transport to a hospital, as deemed necessary by the chapter advisors. I have listed above all medical conditions that might affect him/her. I understand that Brighton FFA does not carry accident insurance for members, and certify that the above student is covered by medical insurance that will allow him/her to receive necessary emergency care in the event of injury or illness.

______Signature of parent or guardian telephone number

Emergency Name’s and phone number: ______

______

***I also give my permission for chapter advisors to administer the following general medications from their first aid kit if needed to my son or daughter.

____”Pain Aid”- fast, safe head ache/pain relief ____ “Un-Aspirin” – pain reliever ….contains no aspirin ____ “Congest Aid” – nasal decongestant ____ “Dilotab” – hay fever, sinus, and cold relief ____ “Midol” – cramp relief