Medical Form and Photo Release
Must be submitted to outing coordinator one
week prior to departure on outdoor trip.
Child's name __________________________________Child's
grade_______
Address______________________________________Phone
____________
Medical information:
Please list any personal medical condition(s)
that you feel the leaders should be aware
of. Include any physical conditions (heart
condition, recent surgery, recent sprains
or strains, reactions to extremes of temperatures,
frostbite, chronic or recurring illness,
disorders, allergies, diabeties, etc,...
______________________________________________________________
______________________________________________________________
Will the participant be taking any medication(s)
during the activity? ____(Yes/No) If so,
please list them and what condition(s) they
are for. _________________________________________________________________________
Does the participant have food allergies
or special dietary requirements? If so, please
specify: ____________________________________________________________________.
Sex (M? F?) Height__________ Weight _____________
Age ________
In case of emergency notify:
Name __________________________________________Relation
________
Telephone (day) _____________ Telephone (Evening
)_______________
Address _______________________________ City/State________________
Parent/Legal guardian Insurance Company_____________________________ID#_________
Student's Social Security Number ____________________________
In case emergency medical treatment is required:
I, ___________________________________, the
parent/legal guardian of _______________________________,
give permission to the Mid-Hudson Adirondack
Mountain Club outing leader(s), to sign for
emergency medical treatment for my child,
should the need arise. I understand that
every attempt will also be made to immediately
contact me.
Parent/legal guardian signature _______________________________________________
Date___________
Photo Release
I, ______________________________________,
the parent/legal guardian of
____________________________________________
grant to the Adirondack Mountain Club the
right to take and publish photographs of
my child in the midst of outdoor activities.
I understand that the photographs could be
published in newspapers, magazines, brochures
and advertising.
Parent/legal guardian signature _______________________________________________
Date __________