Loading… BROTHERS AND SISTERS EMERGING Programing & Camp Medical Release Form Child's First Name Child's Last Name Age Parent/Guardian Name Emergency Contact Name Phone Family Doctor’s Name Phone Doctor’s Address Health Insurance Provider Group #: (Optional: Only in case of emergency) Does your health insurance have any special instructions in case of emergency that we should be aware of if you are not immediately available? YES NO If, yes please explain The medical services are provided without gratuity. Therefore, we will not assume any liability due to injury on the field. If you have any medical training and would like to volunteer your time, please let us know. All are welcome. CHILD’s HISTORY: Does your child currently have any of the following OR has your child ever been diagnosed with any of the following? Please answer YES or NO Bleeding Tendencies YES NO Allergies YES NO Pneumonia YES NO Rheumatic Disease YES NO Bronchitis YES NO Anemia YES NO Spinal Disease YES NO Fractures YES NO Surgery YES NO Knee Problems YES NO Asthma YES NO Bone Disease YES NO Covid 19 YES NO Does your child take any routine medications? YES NO Does your child have any physical handicaps? YES NO Any problems with vision or hearing? YES NO Any unusual shortness of breath? YES NO Any recent weight changes? YES NO I feel that my child is physically fit to participate in calisthenics and contact practice or scrimmages. I shall not hold the Garfield Youth Sports (GYS) football and/or cheerleading, or organizers responsible for any problems arising because of a previous health problem or injury. Type In Your Name As Your Signature Date Send
