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The Korean Youth Center of New York 2013

2013 Medical Release FormThis form MUST be completed and submitted

I. STUDENT INFORMATION

Student Name: __________________________________________________ DOB: ___ / ___ / ______Address: _____________________________________________________________________________

City: _______________ ________ State: ______________________ Zip Code: ___________

Email: ________________________________________________ Cell Phone: ____________________

Parent / Guardians Name: ______________________ Relationship to Student: __________________

Home Phone: (____) __________ Work Phone: (____) __________ Cell Phone: (____) __________

Secondary Contact to notify in case of emergency: ____________________________________________

His / Her relationship to you: ______________________________ Phone Number: (____) __________

II. MEDICAL INFORMATION

Please supply ALL of the information. If you DO NOT have an insurance policy, please check the box

below. If you do have insurance, please attach a COPY of your Insurance Card.

I DO NOT HAVE HEALTH INSURANCE

Medical Insurance Company: ____________________ Group #: __________ Policy #: ___________

Companys Address: _________________________________ Companys Phone: (____) __________

Physicians Name: ________________________________________ Phone Number: (____) __________

Physical Limitations (Asthma, Diabetes, ALLERGIES, etc.), and/or Special Instructions

(Allergic to Certain Medications, Rare Blood Type, Wears Contact Lenses, etc.)

_____________________________________________________________________________________

_____________________________________________________________________________________

List ALL medications taken on a regular basis and / or brought with you during the activity:

_____________________________________________________________________________________

_____________________________________________________________________________________

List ALL operations and / or serious injuries and dates that have occurred within the past 5 years:

_____________________________________________________________________________________

_____________________________________________________________________________________

Date of Last Tetanus Shot: _______________________________________________________________

The Health History is correct as far as I know, and the person herein described has permissions to

engage in all prescribed activities as noted.

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The Korean Youth Center of New York 2013

III. Authorization & Release

EMERGENCY AUTHORIZATION:

I hereby grant permission to the medical personnel selected by the Korean Youth Center of New York /

the designee (staff member) or event coordinator to order X-rays, routine tests, and treatment for my

child. In the event of an emergency, and neither the secondary contact nor myself can be reached, I

hereby give permission to the medical personnel selected by the Korean Youth Center of New York or

designee to hospitalize, secure proper treatment, order injections and / or anesthesia and / or surgery

for my child as named above. I further authorize the release of the above medical information to the

appropriate medical personnel and / or the health coverage insurance company.

In addition, I have, and do hereby, release THE KOREAN YOUTH CENTER OF NEW YORK, its pastors,

employees or agents from liability associated with participation in any of the Korean Youth Center of

New Yorks activities for one year from the date of signature & notarization below.

PHOTO RELEASE:

This document serves as a release for my child(ren) to appear in photographs and / or videotapes while

participating in the Korean Youth Center of New Yorks activities for the purpose of the organization

including, but not limited to, the organizations website, staff training and / or promotion.

________________________________________________ ___________________

Signature of Parent or Legal Guardian Date

I _____________________________________, understand and agree to abide with the restrictions

placed on my activities by my parent / guardian.

________________________________________________ ___________________

Signature of Participant Date

The Following shall be completed by the notary witnessing the parent / guardians signature:

The State of ____________________________ the county of ____________________________

Before me, a Notary Public, on this day personally appeared _______________________ known to

me (or provided to me on the oath of ___________________________________) to be the person

whose name is subscribed to the foregoing instrument acknowledged to me that he / she executed

the same for the purpose and consideration therein expressed. Given under my hand and the seal

of the office this _______ day of _____________, A.D. __________________.

____________________________________________________ Notary, State of

_______________________________________ Print name of Notary Public Here My commission

expires on the ________ day of _______________, A.D. __________________.