Adult Medical Release | SchooloftheGreenwood

2023 Medical Release

Contact

Participant Name

Participant Date of Birth

Preferred Pronouns

Your Phone

Address

Who to Contact in Case of Emergency

Primary Contact Email

Primary Contact Phone

Secondary Contact Name

Secondary Contact Phone

Medical Insurance and Physician

Name of participant's medical nsurance provider and group plan number.

Personal/Family Physician

Physician Phone

Medical History

Date of last tetanus booster

Does the participant have any medical conditions, illnesses, disabilities, limitations, or allergies?

Does the participant take any medications?

Does the participant have any special food needs?

Has the participant been stung by an insect? If so, please explain what kind of insect and if there was an allergic reaction

Medical Release

By signing below, I acknowledge that the information I have provided on this form is accurate and up to date. I will be responsible for resubmitting this form, if changes occur, to ensure that Greenwood staff have accurate and up-to-date medical information regarding the participant.

Your Signature

Your form has been submitted. Thank you!