Fillable Printable Medical Liability Release Form

Medical Liability Release Form

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MEDICAL LIABILITY RELEASE FORM

DIRECTIONS: Due to legal restrictions, it is necessary that all delegates, parents/guardians/chaperones, guest and

HOSA advisors complete this form as a prerequisite for eligibility to attend any HOSA Leadership Conference. The

HOSA chapter advisor should keep the original copy for the State Conference. For National Conference, the original

forms are sent to the State Advisor who forwards them to National HOSA.

PLEASE TYPE OR PRINT ALL INFORMATION

Delegate’s Name: _________________________ Parent/Guardian’s Name: _____________________________

Home Address: ____________________________________________________________________________

Parent/Guardian Telephone:

Home:

_________________________

Work:

Cell:

________________________

Delegate’s Physician: _________________________ Dr. Phone Number: _____________________________

Physician’s Address: ____________________________________________________________________________

Alternate Contact: ____________________________________________________________________________

Telephone Number: Home: _________________________ Work: _____________________________

Local Advisor: ____________________________________________________________________________

School Name: ____________________________________________________________________________

Student 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. Allergy: ____________________________________________________________________________

b. Physical Handicap: ____________________________________________________________________________

c. Convulsions: ____________________________________________________________________________

d. Medicine Reactions: ____________________________________________________________________________

e. Blackouts: ____________________________________________________________________________

f. Disease of any kind: ____________________________________________________________________________

g. Heart or lung problems: ____________________________________________________________________________

h. Other (Be Specific): ____________________________________________________________________________

If currently taking medication, please provide the following information:

* Name of medication: ____________________________________________________________________________

* Prescribing Physician and 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. 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.

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__________ 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 ________________

(the above line is applicable for delegates under the age of 18 and must be signed by the parent or legal guardian.)

Delegate’s Signature ____________________________________________ Date ________________

Advisor's Signature ____________________________________________ Date ________________