Medical Release and Permission Form

00:00

Until your session expires

Your Details

Individual

Business/Organization

Business/Organization*

First Name*

Last Name*

Email*

Phone number*

Ext.

Work Mobile Home

Address Line 1*

Address Line 2

City*

State/Province*

Postal Code*

Country*

Make this activity anonymous This option will hide your name from the activity feed; However, the organization will still receive your information.

Message of Support (Will be displayed on public site)

Additional Information For Your Permission Form(s)

1 X Medical Release and Permission Form

Teen Information

Name:

Required

Characters Remaining: 500

Cell Phone:

Optional

Characters Remaining: 500

Email:

Optional

Characters Remaining: 500

Age:

Required

Characters Remaining: 500

Date of Birth:

Required

Parent/Guardian Name:

Required

Characters Remaining: 500

Parent/Guardian Cell Phone:

Required

Characters Remaining: 500

Parent/Guardian Email:

Required

Characters Remaining: 500

Second Parent/Guardian or other Emergency Adult Contact Name:

Required

Characters Remaining: 500

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

Required

Characters Remaining: 500

Second Parent/Guardian or other Emergency Adult Contact Email:

Required

Characters Remaining: 500

Insurance Information

Company:

Required

Characters Remaining: 500

Policy Type:

Required

Characters Remaining: 500

Policy Number:

Required

Characters Remaining: 500

Phone:

Required

Characters Remaining: 500

Medical Information

List all prescription medications used (with dosage):

Required

Characters Remaining: 2000

For what condition(s)?

Required

Characters Remaining: 500

List any physical disabilities or limitations:

Required

Characters Remaining: 500

List any known allergies and reactions:

Required

Characters Remaining: 500

List any major illness or injuries in the last year:

Required

Characters Remaining: 500

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

Type your name to sign:*

Birth Date:*

Month

Day

Year

IP: 3.230.152.133
Jun. 10, 2023

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Your Details

Additional Information For Your Permission Form(s)

1 X Medical Release and Permission Form

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