Lamb'S Basket Food Pantry Medical Release Form printable pdf download

LAMB’s Basket Food Pantry

Medical Release Form

(Required for ALL Volunteers under the age of 18 years NOT ACCOMPANIED BY A PARENT OR GUARDIAN while at the pantry)

Child’s Name _______________________________________________ Date of Birth _______________________ Age: _______________

(Please Print)

Child’s Address ___________________________________________________________________________________________________

City/State/ZIP ____________________________________________________________________________________________________

Name of Parent/Legal Guardian: _____________________________________________________________________________________

(Please Print)

Address: (If different from Child’s Address) ____________________________________________________________________________

City/State/ZIP ____________________________________________________________________________________________________

Emergency Contact

Father:

Mother:

Home Phone Number: _________________________________

_______________________________________

Work Phone Number: _________________________________

_______________________________________

Cell Phone Number: __________________________________

_______________________________________

Other Guardian Contact (Relation to Minor Child): _____________________________________________________________

Name: ______________________________________________________

Address: ____________________________________________________

Home Phone: ________________________________________________

Work Phone: ________________________________________________

Cell Phone: _________________________________________________

MEDICAL INFORMATION:

Allergies (Food/Medication) __________________________________________________________________________________________

Any medical condition or medical history that should be known to the staff: ___________________________________________________

Date of last Tetanus Shot: _______________________________________________________

Name of Primary Care Physician: _________________________________________________ Phone: _______________________________

MEDICAL FACILITY PREFERENCE:

Hospital: ____________________________________________________________________

Other Medical Center: _________________________________________________________

INSURANCE INFORMATION:

Medical Insurance Provider: ____________________________________________________ Group No.: ____________________________

Policy Number: ______________________________________________________________

Insured’s Name: __________________________________________________ Relationship to Minor Volunteer: ______________________

*** IMPORTANT: Attach a copy of the Insurance Card to this form - Form will not be accepted without this attachment ***

In the event of a medical emergency and a parent or other contact person named above cannot be reached, I authorize LAMB’s Basket

Management Staff/Other Adult Volunteer(s) to obtain emergency medical treatment for my child, and I further authorize any licensed physician to

examine my child and render such medical and/or surgical treatment which, in such physician’s reasonable judgment, may be deemed necessary

for my child’s health and safety.

RELEASE/HOLD HARMLESS: The undersigned hereby releases LAMB’s Basket Management Staff/Other Adult Volunteer(s) from and against any and

all liability arising out of the above child’s volunteer services to the LAMB’s Basket, including but not limited to all claims for personal injury while in

volunteer services at the LAMB’s Basket and/or all claims for medical services rendered.

Signature: __________________________________________

Date: __________________________________

Printed Name: _______________________________________

Relationship to Child: _____________________

(Approved for use by Legal Counsel September 27, 2012)

Lamb'S Basket Food Pantry Medical Release Form

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