AEYF Medical Release Form (please fill in the blanks)
Conference: ______________________
Date:_________________
Location:____________________
Name________________________________________________________________________________
Birth Date________ /________ /________________ (MM/DD/YYYY)
Address________________________________________________________________________________
City_________________________ State________________ Zip/Postal Code_____________________
Cell Phone (_________ )_________ -________________ E-Mail Address ______________________
Father's Name____________________________________ Phone (_________ )__________ -________________
Mother’s Name____________________________________ Phone (_________ )__________ - ________________
Name and Phone of other Relative or Neighbor if parents cannot be reached.
Name____________________________________ Phone (_________ )__________ -
Family Doctor ____________________________________ Phone (_________ )__________ -
For this Period Month/Day-Day/Year __________/_____to_____/________ we authorize Rev. Ara Jizmejian or his designated alternate to obtain emergency medical treatment for the individual listed above, including hospitalization, injections, anesthesia or surgery.
Important medical information (medicines being taken, allergic reactions to any medication, important medical history.):
Insurance Carrier ___________________________________________________________________________
Policy #___________________________________________________________________________
Signature of Participant _________________________________________________________________
Date______ /______ /_____________
Signature of Parent or Guardian_________________________________________________________________
Date______ /______ /_____________
ATTENDANCE AT CONFERENCE DENOTES IMPLICIT ACCEPTANCE OF AEYF POLICIES, RULES AND BYLAWS.
