Medical Liability Release Form printable pdf download

MEDICAL LIABILITY RELEASE FORM

(PAGE 1 OF 2)

SCHOOL:______________________________________________________________________

ADVISOR:_____________________________________________________________________

DIRECTIONS: Due to legal restrictions, it is necessary that all delegates, parents/guardians, guests, and advisors

complete this form to be eligible to attend the FBLA activities. This form should be returned to your FBLA Chapter

Advisor before the first conference that you will be attending.

PLEASE TYPE OR PRINT, LEGIBILY, ALL INFORMATION

Delegate

Parent/Guardian

Home Address

Parent/Guardian/Telephone: Home:

Work:

Student's Physician:

Phone:

Physician's Address

Alternate Contact:

Alternate's Telephone: Home:

Work:

Local Advisor:

School Name:

Student is covered by group or medical insurance:

_____Yes _____No

If yes, complete the following information:

Name of insured:

Insurance Co.

Group #:

Policy #:

Please completely describe any medical condition which may recur or be a factor in medical treatment:

a. Allergy:

e. Physical Handicap:

b. Convulsions

f. Medicine Reactions:

c. Blackouts:

g. Disease of any kind:

d. Heart/lung problems:

h. Other (Be specific):

If currently taking medication, please provide the following information:

Name of medication:

Prescribing Physician:

Physician's Phone #:

LIABILITY RELEASE: I certify that the information described above is accurate and complete to the best of my

knowledge. I understand that each individual is responsible for his/her own insurance coverage during this trip.

I hereby release the National FBLA Board of Directors, the National Staff, State and Local FBLA Associations,

their Staff, and any designated individual in charge of the FBLA group or specific activity from any legal or

financial responsibility with respect to my personal or my student/child's participation in or contact with any known

element associated with an activity including competitive events.

PARENT/GUARDIAN: Please check one of the following and sign your name.

_____I give my permission for immediate medical treatment as required in the judgment of the attending physician.

Notify me and/or any persons listed above as soon as possible.

_____I do not give my permission for medical treatment until I have been contacted.

_____FBLA may use my image in printed and electronic publication.

Parent/Guardian's Signature:

Date:

(Applicable for delegates under the age of 18 and must be signed by the parent or legal guardian.)

Delegate's Signature:

Date:

Advisor's Signature:

Date:

MEDICAL LIABILITY RELEASE FORM

(PAGE 2 OF 2)

SCHOOL:______________________________________________________________________

Medical Liability Release Form

Related Articles

Related forms

Related Categories