Medical
Release And Wavier
Beach
Reach South Padre Island
This form is to be filled
out by all Beach Reach participants and is to be kept with the
group leader and a copy
given to the Beach Reach office.
PERMISSION FOR TREATMENT
My permission is granted for the staff
or a participant of the Beach Reach trip
to obtain necessary medical attention
in case of sickness or injury for (name)______________________________________________.
MEDICAL AND PROPERTY
WAVIER
I, the undersigned, do hereby release
and forever discharge all sponsors,
Beach Reach, and my sponsoring group 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____________________,
20_____.
Signature of Participant____________________________
MEDICAL HISTORY
Name___________________________________Date
of Birth___/___/_____
Address___________________________________________________
City _________________ State _____________
Zip _______
Phone(_____)_____________
SS#___________________________
What medication will you be taking while
on this trip?____________________
____________________________________________________________
Do you have any medical problems that
might affect you while on this trip? ________________________________________________________
Immunizations:___Tetanus
____Polio Booster ____Measles ____Mumps
Other: _______________________________________________________
PAST MEDICAL
HISTORY
Asthma__ Bronchitis__
Sinusitis__ Kidney Problems__ Heart
Trouble__ Diabetes__ Stomach
Troubles__ Hay Fever__
Allergies (Please list any a physician
would need to know, ie. foods, penicillin,
insect bites, etc.) _______________________________________________
Other ___________________________________________________
In Case of Emergency
Notify
Name____________________________________Phone(_____)__________
Name____________________________________Phone(_____)__________
Family Doctor______________________________Phone(_____)__________
Family Insurance Co._____________________________________
Policy #___________________________