Medical Information/photo Release For Volunteers And Minor Children printable pdf download

Medical Information/photo Release For Volunteers And Minor Children

Medical Information/Photo Release

for Volunteers and Minor Children

Parents/Guardian Name/Volunteer Name

_____________________________________________________ Date ________

Address __________________________________________________________________________________

Minor Child’s:

Name ___________________________________________________________________ DOB ____________

Allergies______________________________________ Medical/Special Problems_______________________

Medical Insurance Information

Name of Insurance Company __________________________________________________________________

Policy/Group ID Number ______________________________________________________________________

Name Phone Number

Family Physician(s)___________________________________________________________________________

Siblings over 18 years________________________________________________________________________

Grandparents_______________________________________________________________________________

I/We, being the parent(s) or legal guardian(s) of the above named minor children herby appoint MTG

to act in my/our behalf in authorizing unexpected medical care, dental care, and hospitalization

for the above named minor(s) during the period of my/our absences from:

_________________________________through ___________________________________

Month/day/year

This document shall be presented to a physician, dentist, or appropriate hospital representative

at such times as unexpected medical care, dental care, and/or hospitalization may be required.

Parent/Guardian /Volunteer

__________________________________________________________________________________________

Signature

We, the parents can be reached in an emergency:

Place: _________________________________________ Phone: ________________________

MTG sometimes uses photos from classes/events for use in publicity materials. Children’s names will

be withheld from these materials unless parent consent is obtained. I authorize the use of my/my child’s

photo for publicity purposes.

 Yes, I consent use of my photo/my child’s photo for MTG publicity purposes.

 No, I do not wish for my photo/my child’s photo to be used for MTG publicity.

PO Box 481* Monroe WI 53566 * 608.325.1111*

Medical Information/photo Release For Volunteers And Minor Children