MCPAL Medical and Emergency Information Form

Email address *

Section 1

Personal Information (Some of the personal information is required for grant funding)

Participant's Name *

Date of Birth *

YYYY

Current School *

1st or 2nd Session Preference *

Grade *

Sex *

Race *

Parent/Guardian Name(s) *

Address *

Phone (primary and secondary) *

Email *

Emergency Contacts - In case child listed above becomes ill or is injured and I (parent/guardian) cannot be contacted, the MCPAL volunteers have my permission to contact and release my child to the custody of one of the following: Please provide Name, Relationship, and Primary and Secondary Phone Numbers *

Section 2

Medical Information

Does participant have any dietary restrictions or food or other allergies? *

Yes

If Yes, Please briefly explain:

Does participant have any pre-existing health conditions that may require treatment? *

Yes

If Yes, Please briefly explain:

Is participant currently taking any medications? *

Yes

If Yes, Please list and explain:

Family doctor's name and phone number: *

Preferred Hopsital For Treatment: *

AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S)

As custodian of the aforementioned minor, I grant my authorization and consent for a designated adult to administer general first aid treatment for minor injuries or illnesses. If the injury or illness is severe, I authorize him or her to seek professional emergency personnel to attend, transport and treat the minor and to issue consent for any medical care deemed advisable by a licensed medical professional or institution. I authorize the designated adult to exercise best judgment upon the advice of medical or emergency personnel.

I also understand it is my responsibility to update and complete a new form any time ant of the contact or medical information provided above changes.

Electronic Signature *

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