Medical Info & Release Form
Medical Info & Release Form
Please complete this form for the 2018/19 school year so we have accurate information for all SURGE events your youth will attend. Please complete one form for each of your youth.
Youth Name (Last, First, Middle)  * 
Age  * 
Birthdate xx/xx/xxxx  * 
Parent/Guardian Name(s)  * 
Home Address  * 
City, ZIP  * 
Emergency Contacts:
Home Phone  * 
Cell Number(s)  * 
Medical Conditions and/or Restrictions * 
Allergies * 
Current Medications * 
In the event of a medical emergency or surgical treatment to protect his/her health and welfare while participating in a ValleyView youth event, I authorize and give consent to the administering of such necessary medical and/or surgical treatment. Please type your full name to give consent.  * 
Your Email Address  * 
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