Medical Release and Permission Form

Contact Info

Individual

Business

First Name*

Last Name*

Email*

Phone *

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Address Line 1*

Address Line 2

City*

State/Province*

Postal Code*

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Additional Information for Your Permission Form(s)

1 X Medical Release and Permission Form

Teen Information

Name:

Cell Phone:

Email:

Age:*

Date of Birth:*

Parent/Guardian Name:*

Parent/Guardian Cell Phone:

Parent/Guardian Email:

Second Parent/Guardian or other Emergency Adult Contact Name:

Second Parent/Guardian or other Emergency Adult Contact Cell Phone:

Second Parent/Guardian or other Emergency Adult Contact Email:*

Insurance Information

Company:

Policy Type:*

Policy Number:*

Phone:*

Medical Information

List all prescription medications used (with dosage):

For what condition(s)?*

List any physical disabilities or limitations:*

List any known allergies and reactions:*

List any major illness or injuries in the last year:*

Read and Sign Waiver

PARENTAL RELEASE:
In an emergency, illness, injury, or accident requiring medical attention, I give my permission to LIFECYCLES leaders, its representatives, and all attending healthcare professionals for my child to administer medical treatment, hospitalize, anesthetize, or perform surgery. I understand that every effort will be made to contact before these actions are taken. I, the undersigned, do release, acquit, and discharge damages or liabilities arising from the treatment of any illness, injury, or accident incurred during my child’s participation in these activities. It is the intention of this release that the above LIFECYCLES leaders and representatives incur no liability while attempting to meet all medical needs that my child may require during these activities. I agree to the following:
- I am legally responsible for the above-identified participant.
- I grant full permission to participate in these activities.
- I grant permission to use photos or videos of my child LIFECYCLES promotions, printed material, and social media.
- I agree to the release described above.

I agree

Your birthdate

IP: 44.220.247.152
Sep. 20, 2024

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