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. Child’s Name* Date of Birth* HEALTH:GoodPoor Parent/Guardian Name* Date* Emergency Contact Person* Address* Phone* [cf7mls_step cf7mls_step-1 “Next” “”] 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 –YesNo Penicillin –YesNo Convultions –YesNo Insect Stings –YesNo Diabetes –YesNo Foods –YesNo Ear Infections –YesNo Plants –YesNo Chicken Pox –YesNo Hay Fever –YesNo Measles –YesNo Topical Ointments –YesNo German Measles –YesNo Other Rheumatic Fever –YesNo Mumps –YesNo Uses an Inhaler –YesNo Corrective Device –YesNo [cf7mls_step cf7mls_step-2 “Back” “Next” “Step 2”] ADDITIONAL INFORMATION If yes to allergies, please specify allergy and describe reaction: List significant illnesses or surgeries. Provide dates & instructions: Does your child have any medical restrictions?–YesNo If yes, please explain: Is your child taking medication?–YesNo If yes, please explain: Does your child have any academic or behavioral issues?–YesNo If yes, please explain: Are there any activities that your child cannot participate in?–YesNo If yes, please explain: Do you give permission to PAL staff to apply sunscreen or other over the counter topical ointments on your child?–YesNo [cf7mls_step cf7mls_step-3 “Back” “Next” “Step 3”] INSURANCE INFORMATION Child’s Doctor*: Doctor’s Telephone*: Child’s Insurance Company*: ID Number*: GROUP Number*: [cf7mls_step cf7mls_step-4 “Back” “Next” “Step 4”] 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. Parent/Guardian Signature*: Date*: [cf7mls_step cf7mls_step-5 “Back” “Step 5”]
