Fulton-Montgomery Community College Fencing Club - Minor Treatment Form
Name of Minor- Birthdate -
Insurance Company -
Policy Number or Group Number - Social Security Number -
MEDICAL INFORMATION -
Allergic Reactions -
Current Medications -
Last Tetanus Shot -
Other relevant information if treatment is necessary -
EMERGENCY PHONE NUMBERS -
Father - Home -

Father - Work -

Mother - Home -

Mother - Work -

Number to call if parents cannot be reached -
PLEASE CHECK ONE OF THE FOLLOWING OPTIONS AND SIGN -
______ I grant permission of Michael McDarby or an adult designated by him to act on my behalf for said minor in granting permission for evaluation and treatment of medical problems. I understand that if a serious medical problem should arise, an attempt will be made to notify me by telephone. In the event that I cannot be reached, I hereby give my consent to such treatment as deemed necessary (including surgery, X-ray examinations and anesthesia to be rendered to said minor by a licenced physician or nurse).
______ I authorize limited care as follows:

Full name of father -
Full name of mother -
I, ____________________________________________, declare that I am the Father / Mother / Guardian of the above named minor (circle the correct title).





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                       SIGNATURE                                                       Date