Youth Medical Release Form

Youth Medical Release Forms give one a concise medical history of the applicant. It is a record of the applicant’s blood type, any specific allergies and an overview of any illnesses. It is a release and a waiver form which releases the institution from any liability vis-à-vis the student. By signing this form the guardian takes full responsibility for the ward.

Sample Youth Medical Release Form

Applicant’s name :       _____________________________________________________

Age   :       ­­­­­­­­­­­­­_________________            Date of Birth       :        _______________________

Sex   :       _________________            Phone No   :       _______________________

Contact no in case of emergency   :       _________________________________________

Address     :       ___________________ Street                :       ________________

City           :       ___________________ Zip            :       _________________

Guardian’s Name :       ______________________________________________________

Relationship to the Applicant          :        __________________________________________

Address     :       ___________________ Street                :       __________________

City           :       ____________________       Zip            :       __________________

Alternate contact no    :        ______________________________________________________

Doctor’s name    :       ____________________       Phone no   :        __________________

Insurance Policy no     :        ______________________________________________________

Name of Insurance Company        :        ________________________________________________

Medical Conditions

Dietary Specification (Veg/NonVeg)        :        __________________________________________

Any Medical Conditions :       ________________________________________________

Details of Vaccinations given :        ________________________________________________

Is the applicant on any medications currently? :       ______________________________

______________________________________________________________________________

Does the applicant have any specific allergies? if yes then please specify   : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does the applicant have any physical disability? If yes then please specify   :

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_____________________________________                  ________________________

Parent/Guardian signature                                            Date

Category: Release Forms