Demolay International Medical History And Release Form
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1THE SUPREME COUNCIL - DEMOLAY INTERNATIONAL
MEDICAL HISTORY AND RELEASE FORM
21
(Required for all participants under
years of age)
IDENTIFICATION OF MINOR PARTICIPANT
NAME
__________________________________________________
STATUS:
( ) ACTIVE DEMOLAY
ADDESSS __________________________________________________
( ) VISITOR
CITY
__________________________________________________
STATE
__________________________________________________
ZIP _____________
AGE _________
I hereby promise to conduct myself in a responsible manner and abide by the DeMolay rules and regulations; and to follow all of
the rules and regulations of this DeMolay event. If I do not abide by this promise, I will be subject to being returned home
immediately at my own expense. I shall indemnify and hold DeMolay International, The International Supreme Council of the
Order of DeMolay, and all Affiliated Organizations harmless from and against any and all penalties, losses, costs, damages, suits,
judgments, claims, demands, expenses and liabilities of any kind or nature whatsoever, arising directly or indirectly out of or in
connection with my attendance at this DeMolay event.
(Participant’s Signature)
(Date)
Health History – DeMolay should be aware that this participant has experienced problems with the following:
Appendicitis
Ear trouble
Frequent Colds
Rheumatic Fever
Convulsions
Epileptic Seizures
Heart Trouble
Sinus Trouble
Cramps in water
Fainting
Hernia
Throat Infection
Diabetes
Other
Food Allergies
CONSENT AND RELEASE
I, the undersigned Parent or Legal Guardian of the above identified minor, do hereby give my consent and permission for him/her to
participate in all activities and events conducted by ___________________________________________________, I agree to
release and hold harmless members, advisors and officers of DeMolay International, from any and all claims or cause of action,
which the undersigned has or may have. In the event of injury or illness to the above named minor, I hereby authorize any adult
Advisor in attendance to secure, and any physician in attendance to provide, such emergency treatment as may be deemed necessary
by those present including but not limited to hospitalization, injections, anesthesia, surgery, diagnostic radiology, blood
transfusions, and medication. I understand that reasonable efforts shall be made to contact me prior to medical treatment.
_____________________________________________________
(Parent or Legal Guardian signature)
(Date)
I may be reached at the following numbers during the above-described event.
HOME (
) - ___________________
WORK (
) - ___________________ OTHER (
) - ______________
Medical Insurance Information
Insurance Carrier:
Policy Holder:
Policy/Group Number:
For Emergency Authorization Contact:
Telephone Number:
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