FA Medical Form

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MEDICAL AUTHORIZATION


	Participant Name: ________________________

	Event: _________________________________

	Date(s): _______________________________


	I hereby give permission to the medical personnel selected by my assigned chaperone to order x-rays, routine tests and treatment for applicant as named above; and in the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the chaperone to hospitalize, secure proper treatment for and to order injection, and/or an anesthesia and/or surgery for applicant as named above during the dates specified above.

	__________________________________ Parent / Legal Guardian (Signature)	Relationship to Participant: ___________________________

	Date: _____________________________	Participants Date of Birth: ____________________________

	Phone Number(s): ___________________________________	__________________________________

	Doctor's Name: _____________________________________	Doctor's Phone Number: _____________________________

	Insurance / Medicare Information: ____________________________________________________________________________
	_________________________________________________________________________________________________________


	Please List any Allergies to Foods and/or Medications: ____________________________________________________________
	_________________________________________________________________________________________________________


	Please list special instructions or medical concerns: ______________________________________________________________
	_________________________________________________________________________________________________________


	Please list current medications and dosages: ____________________________________________________________________
	_________________________________________________________________________________________________________