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Release Form Apartment Work by vlp17176

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Release Form Apartment Work document sample

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									                                 MEDICAL RELEASE FORM

ACE Academy Personnel:
In the event that ____________________________________________needs medical care during his/her
official participation in the NBCFAE – Washington Suburban Chapter ACE Camp, you have my
permission to arrange for medical treatment when necessary and performed by a licensed qualified
physician. (Parent/guardian named on Academy application will be notified in case of emergency.)


Student Name _________________________________________________________________________


Address    ____________________________________________________________________________
                 Street                                                           Apartment No.

           ____________________________________________________________________________
                 (City)                               (State)                              (Zip)

Date of Birth: Month ________________________ Day _______________ Year ________________

Home Phone No: (          ) __________________ Parent/Guardian Work No. (             ) ________________

Medical/Health Insurance Company ________________________________________________________

I.D.#, Group/Contract#, Benefit# ___________________________________________________________

Does student have allergies to medication or other important medical factors? (     ) Yes (        ) No

If yes, please explain _____________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Prescribed medication/condition or physical handicap __________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Person other than parent/guardian to be contacted in case of emergency:

Name _____________________________________             Phone No. (          )_________________________

Relationship to Student ___________________________________________________________________




__________________________________________                                ____________________________
               Parent/Guardian Signature                                  Date

								
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