The following form is a sample/suggestion medical form for participants in the Mechanicsville Christams Parade. You may also download a copy of this form in Microsoft Word.

(Please print or type all information and attach a copy of both sides of your insurance card.)

Name __________________________________ Birth Date ___________________

SS # _________________

I, the undersigned, being the parent or legal guardian of the person named above, hereby authorize any necessary medical treatment for this person while participating in the 2005 Mechanicsville Rotary / Ruritan Christmas Parade. I guarantee payment of all charges incurred for medical treatment (physician, hospital, X-ray, lab, medications, ambulance, etc.) I give my permission for the above named person to receive first aid treatment have administered over-the-counter medicines as the need arises.

1. Allergies to food, medication, etc. (if none, so state)

________________________________________________________________________________

2. Allergies to insect bites and stings. Please describe minor’s reaction and medicine taken (If none, so state)

________________________________________________________________________________

2. Special medical problems (If none, so state)

________________________________________________________________________________

4. Medication taken regularly (If none, so state)

5. Date of last tetanus shot_____________________

Father's Name ____________________________Mother's Name ________________________

Parent's address________________________________________________________________

City _______________________________ State ______Zip _______ Phone______________

Father's work phone ____________________________

Mother's work phone ____________________________

Name of person if parents can not be reached _____________________Phone________

Parent or legal guardian___________________________________ Date _______________

Insurance Company _________________________Policy Number _______________________

Subscribed and sworn to me before this ___________________ day of ______________