Fairwood Bible Institute

MEDICAL RELEASE FORM

I. General Information

1. Name___________________________________ Date of Birth ______________________

   Social Security No_________________________ Place of Birth ______________________

2. Home address_____________________________________ Telephone ____/___________

   City_________________ State___________ Zip__________

3. Father's Name_________________________ Mother's Name________________________

   Address______________________________ State____ Zip_________  Tel.____/________

            Father's work phone #____/________ Mother's work phone #____/________

Nearest relative or person to contact in event parents are not available:

1. Name_____________________  Address______________________ Phone_____________

II. Financial Responsibility

Medical Insurance Information (if applicable, not encouraged)

Insurance Company Name________________________ Policy I.D. #____________________

Home state________

Who carries? ____ Father/Mother ___    With what company? __________________________

III. Health Information

1. Do you have any health condition or physical handicap which requires special attention or have you had any serious illnesses or infectious diseases?

If so, what__________________________________________________________________

(Give full details/attach note)

2. Do you take any medication on a regular basis?____ If so, what?______________________

3. Date of last tetanus booster shot?_________

4. List any hospitalizations (Give full details/attach note)______________________________

5. List any known allergies: Foods______________ Drugs____________ Insects___________ Other_______________________________________________ (Give full details/attach note)

6. Have you ever had?             Rheumatic Fever                                 yes       no

                                                            Diabetes                                  yes       no

            Chicken Pox    yes       no        Seizures                                   yes       no

            Measles           yes       no        Epilepsy                                  yes       no

            Mumps            yes       no        Concussions                            yes       no

                                                            Hepatitus                                 yes       no

                                                            Other_____________________________

7.  Describe your present health including any conditions which might affect your participation in the program (including work and sports) at Fairwood Bible Institute.

 ___________________________________________________________________________

___________________________________________________________________________

IV. Permission/Release

Student has/does not have permission to participate in the full/limited athletic program at Fairwood Bible Institute.

In case of emergency, I hereby give my permission for emergency care.

_________________________________________ Date ______________

Parent's Signature (If student is over 18, student's)