MEDICAL INFORMATION

Must be completed by parent or guardian

    The following member, being of membership age, is able to fully participate in the activities of the Millville PAL and hereby releases the City of Millville, the Millville Police Department, the Millville PAL Organization, including its Board and Directors, or any representative of these organizations from any liability or responsibility for any injury/injuries that may occur.

    HEALTH:


    CONDITIONS & ALLEGIES

    This confidential health record is strictly confidential and will not be shared with anyone without the parent/guardian’s written consent or in case of emergency medical care. Please provide your child’s medical history.

    Conditions Allergies
    Asthma Penicillin
    Convultions Insect
    Stings
    Diabetes Foods
    Ear Infections Plants
    Chicken Pox Hay Fever
    Measles Topical
    Ointments
    German Measles Other
    Rheumatic Fever
    Mumps
    Uses an Inhaler
    Corrective Device


    ADDITIONAL INFORMATION


    INSURANCE INFORMATION


    CERTIFICATION

    I understand that this consent will be in effect as of the date of my signing this form and will continue if my child is enrolled in the PAL program.