VALOR 2009 Medical Release Form

VALOR activities, like any active sport, involve a certain risk of injury.
Should a participant sustain any injuries, VALOR would like to take the appropriate actions to aid him or her. In order to do so, a brief medical record and history is requested. Please fill out this form completely and legibly. The information on this form is required for all admission into any US Hospital.

Participant Name:(please print)

___________________________________

Parent or Legal Guardian:(please print) (if under 18 years of age)

___________________________________

Does the participant have any medical conditions that VALOR or VALOR staff should know about to ensure that participant's safety in the event medical treatment is needed?
If YES, please list all, including allergies (ex: allergy to bee stings), adverse reactions to any medical drugs, asthma, diabetes, fainting spells, heart trouble, convulsions, bleeding disorders, or any other problems.

NO  ______

YES ______

(please explain)

___________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

This health record is correct as far as I know, and person herein has permission to engage in all prescribed activities. In the event that I, or the person listed below, cannot be reached in an emergency, I hereby give permission to have

1) VALOR NERO members render first aid, and

2) Any physician hospitalize, secure proper anesthesia, or order injection for (participant's name).(please print)

___________________________________

Signature of Parent or Guardian (if under 18), or Participant (if 18 or older)

___________________________________

Date:

___________________________________

Parent or Guardian Phone Number:

(___)_______________________________

In case of emergency, contact (or enter NONE):Name:

___________________________________

Relationship:

___________________________________

Address:

___________________________________

Phone:

(___)_______________________________

Medical Insurance Information: (Plan/Policy Number)

___________________________________

Family Doctor:

___________________________________

Phone:

(___)_______________________________