MADE FOR MORE 2015 | 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
When did participant receive the following immunizations:
___Polio
___Diphtheria
___Whooping Cough
Does participant have? (circle all that apply)
Diabetes
Asthma
Heart Trouble
Skin Trouble
Lung Trouble
Allergies
Scarlet Fever
Whooping Cough
___Tetanus Toxoid
Ear Trouble
HIV/AIDS
Hernia
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 2015 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:_________________________