Medical Release And Waiver

 Permission for Treatment

My permission is granted for the Beach Reach staff or sponsor in charge of the trip to obtain necessary medical attention in case of sickness or injury for

Participant’s name

Medical and Property Waiver

I, the undersigned, do hereby release and forever discharge all sponsors, and Beach Reach from any and all claims, demands, actions, or causes of action, past, present, or future, arising out of any damage or injury while participating in this event.

Dated this

of

February

Signature of Participant

 

Medical Information

Full Name
B-day SS#
Address Zip
Phone
E-mail

What medication will you be taking while on this trip?

Do you have any medical issues that might affect you while on the trip?

Immunizations:

_ Tetanus  _Polio Booster  _ Measles _Mumps  _Hepatitis A    _ Typhoid

 Past Medical History

_ Asthma   _  Bronchitis  _ Sinusitis  _Kidney Problems  _Heart Trouble  _ Diabetes _Stomach Troubles   _Hay Fever _ Allergies

Please list any that you have, ie. foods, penicillin, insect bites, etc

 In Case of Emergency Notify

Name

Phone

E-mail

Family Insurance Co

Policy #