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MEDICAL QUESTIONAIRRE AND EMERGENCY MEDICAL

TREATMENT AUTHORIZATION FORM
Please type or print. This form is required for all students attending Key Club International activities. This form MUST be completed by a parent or guardian and
notarized for it to be recognized in many states. One copy of this form is to be turned in at the event. One copy is to be given to the chaperone and one copy is
to be carried by the Key Club member at the activity.

Key Club Member Name: _______________________________________________________________________________________________________________________
Address: ______________________________________________________________________________________________________________________________________
City: ______________________________________________________ State: ______________________________________________ Zip: ___________________________
Height: ________________________ Weight: ________________________ Gender: ________________________ Birth Date: ____________________________________

Primary Emergency Contact: ___________________________________________________________________________________________________________________
Relation to member: ___________________________________________________________________________________________________________________________
Home Phone: ________________________________________________________ Cell Phone: _____________________________________________________________
Secondary Emergency Contact: ________________________________________________________________________________________________________________
Relation to member: ___________________________________________________________________________________________________________________________
Home Phone: ________________________________________________________ Cell Phone: _____________________________________________________________

Personal Physician: ___________________________________________________________________________________________________________________________
Phone: ____________________________________________________ Evening Phone (if applicable): _______________________________________________________
Address: _____________________________________________________________________________________________________________________________________
City: ____________________________________________________ State: ____________________________________________ Zip: ______________________________

Name of Health Insurance Company: ___________________________________________________________________________________________________________
Policy Number: _____________________________________________ Name of Insured: ________________________________________________________________
Employer’s Phone: _____________________________________________ Insurance Company’s Phone: ____________________________________________________
Other pertinent information shown on insurance card: _____________________________________________________________________________________________

Will your son or daughter be taking any drugs or medications of any type? YES_______ NO_______
If yes, please list: _____________________________________________________________________________________________________________________________
Has your son or daughter ever been treated for or is being treated for: (check all that apply)
___ nervousness? ___ rheumatic fever? ___ asthma?
___ convulsion or epilepsy? ___ cancer or tumor? ___ ulcers?
___ fainting spells? ___ high blood pressure? ___ diabetes?
___ heart condition? ___ severe or frequent headaches? ___ allergic reactions to medication?
___ any medical disorder? ___ migraines? ___ strong allergic reactions?
Does your son or daughter have any physical limitations? YES_______ NO_______
For any yes answer in the above section, please give the dates of treatment, and the names and addresses of attending physicians, hospitals and clinics on the
reverse of this page.

NOTARIZATION
Please read carefully:
I hereby certify that the information given above is correct. In case of medical emergency, I understand that every effort will be made to contact the person(s)
designated above. In the event that that/those person(s) cannot be reached or time does not permit, I hereby give permission to a licensed physician to provide
proper treatment, including hospitalization, immunization, and possible injection, anesthesia, or surgery, for my son or daughter.

Signature of Parent(s) or Gaurdian(s): __________________________________________________________ Dated: __________________________________________
__________________________________________________________ iDated: __________________________________________
This document was subscribed and sworn before me this _______________ day of ________________________________ 20____ for the above signed person(s) only.
Signed: _________________________________________________________________________ Notary Public of the County of _________________________________
In the state of ___________________________________________ Affix seal here

My commission expires on: _______________________________

STUDENTS WILL NOT BE ALLOWED TO REGISTER AT KEY CLUB
ACTIVITIES WITHOUT THIS FORM COMPLETED AND NOTARIZED