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:

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    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

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    ADDITIONAL INFORMATION

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    INSURANCE INFORMATION

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    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.

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