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Redmond Release

 

Special Olympics Participation Information

Redmond Regional Medical Center

 

 

Participant Name____________________________________  Social Security #:______-_____-______   Birthday:___/____/____ Parent/Guardian:______________________________________________  Phone No:___________________________________

Address_________________________________________________ City________________ State___________ Zip___________

 

 

Release of Information:

I hereby authorize Redmond Regional Medical Center to furnish necessary private health information to Special Olympics Georgia and to other health providers as necessary.                                Initial ____________

 

 

Consent for Treatment of Minor Child:

Consent is hereby given by the undersigned for examination by personnel of Redmond Regional Medical Center for the purpose of participating in Special Olympics. I acknowledge that Redmond Regional Medical Center personnel are performing a screening examination and that this is not a substitute for regular medical care. I as the undersigned parent or legal guardian of the above named athlete hereby release, discharge and indemnify Redmond Regional Medical Center from all liability for injury to person as a result of said participation. The undersigned states that he/she is the patient’s legal guardian.                  

 

_______________________________________________________                                              __________________

Patient/Parent (if a minor) Signature                                                                                             Date

 

 

List any medications your child is currently taking:________________________________________________________________________

 

List all of your child’s current health problems:______________________________________________________________________

 

List your child’s primary care doctor, any other doctors, and any treatment received and results obtained:

 

Physician Name:_______________________________________ ____                  Phone No.:_________________________________

 

Physician Name:_______________________________________ ____                  Phone No.:_________________________________

 

 

Side 1 of 2                Over

 

 

List all surgeries your child has had and list dates:

 

Surgery:_________________________________________             Date:____________________

 

Surgery:_________________________________________             Date:____________________

 

 

 

Check All That Apply To Your Child:

 

(   ) Heart Palpitations during exercise             (   ) Do you have asthma                     (   ) Unexplained fainting                    (   ) Shortness of breath after 10 mins of exercise

(   ) Frequently complains of fatigue                 (   ) High Blood Pressure                     (   ) Recent Weight Loss                      (   ) Skin rashes, hives, or lesions                             

(   ) Frequent Urination                                       (   ) Abnormally thirsty                        (   ) Frequent nosebleeds                   (   ) Frequent constipation or diarrhea                   

(   ) Numbness or tingling in heads or feet      (   ) Frequent headaches                    (   ) Frequent nausea or vomiting      (   ) Participation in regular exercise and/or school PE

 

 

Family History

           

Mother:__________________________________   Age:____        Father:________________________________            Age:_____

 

 

Please check all that apply to family members (Mother, Father, Brothers, Sisters, Grandmother(s), Grandfather(s)):

 

(   )   Diabetes                             (   )  High Blood Pressure                                (   )  Heart Disease                               (   )  Seizures                         (   )  Asthma 

 
 
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