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 MEDICAL HISTORY AND RELEASE FORM

Participant: Chapter: Age: ____

Address: City: Zip Phone: ________________

* PARTICIPANT'S INDEMNIFICATION *
(REQUIRED BY ALL PARTICIPANTS)
I understand that while on my way to, in attendance at, and returning from any DeMolay activity I will fulfill my DeMolay obligations as well as obey any
special guidelines of that event. I hereby promise to conduct myself in a responsible manner and abide by the DeMolay rules and regulations, remembering that
the future welfare of DeMolay is in my hands. I will not sell, distribute or possess liquor or any illegal drugs. Article 14 of the DeMolay Rules & Regulations
provides for disciplinary measures ranging from reprimand to suspension to exclusion from the DeMolay International.
PARTICIPANT’S SIGNATURE: DATE: / / __
* HEALTH HISTORY *

The participant is permitted to participate in ALL official DeMolay activities and events WITH THE FOLLOWING EXCEPTIONS (e.g.
skiing, swimming. If NONE, write NONE):_______________________________________________________________________

Taking the following prescription medications:

List any allergies or other medical conditions of which we need to be aware
Any dietary restrictions ___________________________________________________________________________________________________________

LAST TETANUS UPDATE:________ MEDIC ALERT:

Name of Medical Insurance:_________ Family Physician: _________________________________________
Company (Employer):______________ Address:_______________
Medical Insurance Group Policy #: City, St. & Zip: _________
Individual Account #:______________ Phone #: ________________i

IN CASE OF EMERGENCY, CONTACT:

Name: Phone # (Day):

Relationship: Phone # (Night):

* PARENTAL PERMISSION, MEDICAL & PHOTO RELEASE *

(Required For All Participants Under 21 Years of Age)

As the Parent or Legal Guardian of the participant named above, I hereby give my permission for any adult DeMolay Advisor in attendance to secure, or any physician in
attendance to provide, such emergency medical treatment as shall be deemed necessary by those present; including, but not limited to, hospitalization, injections, anesthesia,
surgery, x-ray, blood and medications. I understand that every reasonable effort shall be made to contact me or the emergency contact prior to medical treatment. I agree that all
costs associated with the treatment will be paid by the parent(s).

I also agree, upon notification from the DeMolay Staff, to pick up the above named participant, if, in the opinion of the DeMolay Staff, it is necessary that he/she be removed
from the site of a DeMolay event. If I cannot pick-up the named participant, I will make suitable arrangements with the DeMolay Staff to have the participant picked-up or
transported at my cost to his/her home or a suitable relative for supervision. In addition, I agree on behalf of the above named participant, that if the event involves overnight
rooming accomodations, his/her room may be entered if it is deemed necessary by the DeMolay Staff.

On behalf of myself and my ward/minor, I hereby RELEASE, WAIVE AND FOREVER DISCHARGE INDEMNIFY AND HOLD HARMLESS, DeMolay, DeMolay
International, all Affiliated Organizations and its officers, directors, employees, parents and subsidiaries, agents, from any and all claims, liabilities, causes of actions, damages,
demands, judgments, executions, liens and costs whatsoever, in law or equity, including, without limitation, liability for death or bodily injuries to any person or damage to any
property resulting from any (i) claims made against medical providers of emergency services under this authorization, or (ii) against DeMolay, DeMolay International, all
Affiliated Organizations and its officers, directors, employees, parents and subsidiaries, agents for obtaining medical emergency services for said DeMolay member pursuant to
this authorization.

I hereby grant Arizona DeMolay, DeMolay International, all Affiliated Organizations the right to take photographs (still or video) of the participant during DeMolay activities
and use such photographs with or without participants name for any lawful purposes including but not limited to publicity, illustration, advertising, and web content. I authorize
DeMolay, its assigns and transferees to copyright, use and publish the same in print and/or electronically.

(SIGNATURE) DATE: / /
PARENT or LEGAL GUARDIAN

(SIGNATURE) DATE: / /
PARENT or LEGAL GUARDIAN