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Medical Release 2017-2018

                                                                       Student Name:_______________________________________

DIRECTIONS: Due to legal restrictions, it is necessary that all students, parents/guardians, guests and HOSA Advisors complete this form to be eligible to attend and participate in any HOSA activity/conference during the 2017-2018 school year. This form should be returned to the local HOSA Chapter Advisor.  Chapter Advisors will submit a copy during conference registration at State Leadership Conference and then again for all students, parents, guests and HOSA Advisors attending International Leadership Conference.

PLEASE TYPE OR PRINT ALL INFORMATION

HOSA Member/Attendee__________________________________Phone #_____________________

Home Address______________________________________________________________________

Parent/Guardian (if member/attendee is a secondary student)_________________________________

Parent/Guardian Phone #:  ____________________________________________________________

Alternate Emergency Contact: _________________________________________________________

Alternate Emergency Contact Phone #: ___________________________

Local Advisor: ________________________________School Name: __________________________

Local Advisor Cell #:______________________________________

Student/Attendee Physician: ____________________________Phone: _________________________

Physician’s Address: _________________________________________________________________

Student/attendee is covered by group or medical insurance: ¨ Yes ¨ No 

If yes, complete the following information:

Name of insured: ____________________Insurance Company: _______________________________

Group #: __________________________Policy #: ____________________________________­______

Please completely describe any medical condition which may recur or be a factor in medical treatment:

a. Allergies:__________________________ e. Physical Handicap: ______________________________

b. Convulsions: _______________________ f. Medicine Reactions: _____________________________

c. Blackouts: _________________________ g. Disease of any kind: _____________________________

d. Heart/lung problems: _________________ h. Other (Be specific):______________________________

If currently taking medication, please provide the following information:

Name of medication: __________________________________________________________________

Prescribing Physician/Phone Number: _____________________________________________________

LIABILITY RELEASE. I certify that the information described above is accurate and complete to the best of my knowledge. I understand that each individual is responsible for his/her own insurance coverage during this trip/activity. I hereby release the National HOSA Board of Directors, the National Staff, State and Local HOSA Associations, and any designated individual in charge of the HOSA group or specific activity from any legal or financial responsibility with respect to my personal or my student/child’s participation in or contact with any known element associated with an activity including competitive events.

PARENT/GUARDIAN: Please check one of the following and sign your name.

 ¨      I give my permission for immediate medical treatment as required in the judgment of the              attending physician. Notify me and/or any persons listed above as soon as possible.

 ¨    I do not give permission for medical treatment until I have been contacted.

Parent/Guardian’s Signature: _______________________________________ Date ________________

(Applicable for secondary students)

HOSA Member/Attendee Signature: __________________________________ Date ________________

Advisor’s Signature: _______________________________________________ Date _______________

 

Secondary student is defined as a high school student while a HOSA member

Rev 6/2017


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