EITHER A PHYSICIAN’S PRESCRIPTION OR PARENT NOTE MUST ACCOMPANY ALL MEDICATIONS. PRESCRIPTION/NOTE SHOULD BE ATTACHED TO THIS FORM.

 

PHONG TRÀO THIẾU NHI THÁNH THỂ VIỆT NAM TẠI HOA KỲ The Vietnamese Eucharistic Youth Society in the USA

Miền Đông Nam - Southeastern Region

ĐOÀN PHÊRÔ & PHAOLÔ 15 West Par Street ♦ Orlando, Florida 32804 ♦ (407) 451-6574

tranndung@gmail.com

MEDICAL RELEASE FORM

Huấn Luyện Tông Đồ Đội Trưởng

Name of Participant: ___________________________________________ Date of Birth: _______________________

Address: _________________________________________________________________________________________

_________________________________________________________________________________________________

Insurance Carrier: _______________________________ Insurance Policy Number: __________________________

Insurance is provided by which parent and/or employment? _______________________________________________

Address and Phone Number of Company: _____________________________________________________________

Relative or friend to contact if unable to reach parent/guardian in the event of emergency (over 18)

Name: _________________________________________ Relationship: ____________________________________

Home Phone: ____________________________ Cell Phone: ______________________________

Special consideration to be aware of (i.e. allergies, medical conditions, etc.): _________________________________________________________________________________________________ Medication (and dosage) my son/daughter is currently taking: _________________________________________________________________________________________________ As the parent/legal guardian of, _____________________________________________, I request that in my absence the

above named participant be admitted to any hospital or medical facility for diagnosis and treatment. I request and

authorize physicians, dentists and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such

licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and

x-ray treatment of the above minor. I have not been given guarantee as to the results of examination or treatment; I

authorize the hospital of medical facility to dispose of any specimen or tissue taken from the above named player.

Signature of Parent/Guardian: __________________________________ Date: _________________

**Please photocopy insurance card that is to be used and attach it to this form**