Home > Life > Medical Forms > Medical Release Template > Illinois Medical Release Form > Illinois Medical Release Form 1

Illinois Medical Release Form 1

At Speedy Template, You can download Illinois Medical Release Form 1 . There are a few ways to find the forms or templates you need. You can choose forms in your state, use search feature to find the related forms. At the end of each page, there is "Download" button for the forms you are looking form if the forms don't display properly on the page, the Word or Excel or PDF files should give you a better reivew of the page.
This form is provided for the medical and liability release regarding the necessary medical care and treatment to be administered to people attending the State HOSA Conference.

Illinois Medical Release Form 1
Illinois Medical Release Form 1
Page 1 of 2
MEDICAL / LIABILITY RELEASE and CONDUCT CODE AGREEMENT FORM
Due to legal restrictions, it is necessary that all students, chaperones, and HOSA Advisors complete
this form as a prerequisite for eligibility to attend the State HOSA Conference. Chapter Advisor,
please make a copy for your files and mail the originals to the State Conference Manager.
PLEASE TYPE OR PRINT ALL INFORMATION
Name _________________________________________________________________________
(Circle title) Advisor Alumni Chaperone Student Professional
Home Address __________________________________ Home # (_____)________________
City ___________________________________________ Zip ____________________
Parent/Guardian's Name ___________________________________________________________
(If appropriate)
Father Work # (_____)______________________ Mother Work #(_____)___________________
Additional Phone #(____)__________________________________________________________
Alternate Contact ________________________________Relationship______________________
Home # (_____)_________________________ Work # (_____)____________________________
Medical Information:
Physician /Clinic Name _____________________________Office # (____)_________________
If currently taking medication, please provide the following information:
a. Name of medication ____________________________________________________________
b. If different from above Prescribing Physician ____________________________________________
c. If different from above Office # (_____)________________________________________________
Medical insurance: __________ No __________ Yes If yes, complete the following:
Name of Insured _________________________________________________________________
Insurance Company _______________________________________________________________
Group # ______________________________ Policy # __________________________________
Describe any medical concern which may be a factor in medical treatment.
a. Allergy ______________________________________________________________________
b. Physical Handicap _____________________________________________________________
c. Convulsions __________________________________________________________________
d. Medicine Reactions ____________________________________________________________
e. Blackouts ____________________________________________________________________
f. Disease of any kind ____________________________________________________________
g. Heart or lung problems _________________________________________________________
h. Other (please specify) __________________________________________________________
Illinois Medical Release Form 1
Previous

1/2

Next