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 *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Current School *
Your answer
1st or 2nd Session Preference *
Grade *
Your answer
Sex *
Your answer
Race *
Your answer
Parent/Guardian Name(s) *
Your answer
Address *
Your answer
Phone (primary and secondary) *
Your answer
Email *
Your answer
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 *
Your answer
Section 2
Medical Information
Does participant have any dietary restrictions or food or other allergies? *
If Yes, Please briefly explain:
Your answer
Does participant have any pre-existing health conditions that may require treatment? *
If Yes, Please briefly explain:
Your answer
Is participant currently taking any medications? *
If Yes, Please list and explain:
Your answer
Family doctor's name and phone number: *
Your answer
Preferred Hopsital For Treatment: *
Your answer
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 *
Your answer
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