Medical Information and Authorization PARENT/GUARDIAN AUTHORIZATION AND RELEASE

TO BE COMPLETED BY PROGRAM STAFF:

Program/Event Name: ___

Date(s):___

County/Location: ___

Employee Name: _____ Program Area: _____

SECTION 1. PARTICIPANT & EMERGENCY CONTACT INFORMATION

Participant information

Participant Name: ___

Date of Birth: ___ / ___ / ___ Gender: ☐ M ☐ F

Parent/Guardian Information

Parent/Guardian Name: ___

Primary Phone: _____ Secondary Phone: _____

Email: ___

Home Address: ___

City: _____ State: _____ Zip: _____

ADDITIONAL EMERGENCY CONTACT

Primary Emergency Contact (if different from parent/guardian)

Name: ___

Phone: ___ Alternate Phone: ___

Relationship: ___

SECONDARY EMERGENCY CONTACT

Name: ___

Phone: _____ Alternate Phone: _____

Relationship: ___