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Medical Release Form

AYF-YOARF Eastern Region USA / Medical Release Form

AYF Letter Head

AYF-YOARF MEDICAL RELEASE FORM

This form must be completed prior to participation at all AYF events. Please release disclose medical issues in order for the medical staff to provide the best case possible. No information will be disclosed to anyone outside of our medical staff. If there are any issues please contact your Central Executive fieldworker.

    Name *

    First

    Last

    Address *

    Street Address

    City

    State / Province / Region

    Zip / Postal Code

    Email *

    Phone *

    Chapter *

    Event *

    Name of Insurance Company *

    Policy Number *

    Family Physician Name*

    Family Physician Number *

    Allergies

    Food

    Medications

    Environmental

    Have you ever had a blood transfusion?
    YesNo
    If so, did you have any reactions?

    Current Medications

    Medication

    Dosage

    Time Taken

    In case of emergency or serious illness, please contact

    Name*

    Relationship *

    Home Phone *

    Cellular Phone *

    Work Phone *

    In the event that you are unable to notify me or the undersigned parent/guardian, I hereby appoint and authorize the AYF—YOARF Central Executive, its councils or appointee so designated to secure whatever medical or surgical care deemed necessary or reasonable. In the event that the registrant is transported to a local hospital, I hereby authorize a physician to administer treatment and perform other procedures that in their judgment may be necessary.