Medical Form

Michigan District of Key Club International, Inc.
Medical Form

Authorization to attend event and emergency medical

This form is required for all Key Club members attending designated Key Club International events or activities. The parent, legal guardian or person in loco parentis for the member must complete this form.

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Participant Name*
Participant Address*
MM slash DD slash YYYY

Health Insurance*
List Primary and any secondary health insurance coverage. Add rows as necessary.
Company Name
Policy Number
Group name
Telephone Number
List all over-the-counter or prescription medications. Add rows as necessary.
Health History
Check any the participant has ever been or is currently being treated for.
Allergies or Other Medical Conditions
List allergies and/or medical conditions, one per row. Add rows as necessary.
Parent/Legal Guardian Name*
Required to receive a copy of the submitted form.
I am the parent or legal guardian for the above-named Key Club member, and give my permission for him/her to attend the convention, conference and/or other event(s) sponsored by the Michigan District of Key Club International, Inc.. I hereby certify that the information provided above is correct. In the case of medical emergency, I understand that every effort will be made to contact the emergency contacts listed above. In the event those persons cannot be reached or time does not permit, I hereby give permission to a licensed physician or other licensed medical provider, to provide proper treatment, including but not limited to hospitalization, injection, anesthesia and/or surgery, for the above-named Key Club member. On behalf of myself and my ward/minor, I/we hereby RELEASE, WAIVE AND FOREVER DISCHARGE Key Club International and its officers, directors, employees, subsidiaries, agents and parents, from any and all claims, liabilities, causes of actions, damages, demands, judgments, executions, liens and costs whatsoever, in law or equity, including, without limitation, liability for death or bodily injuries to any person or damage to any property resulting from any claims made (i) against medical providers of emergency services under this authorization, or (ii) against Key Club International for obtaining medical emergency services for said Key Club member pursuant to this authorization.
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