DeMolay Parental Consent and Medical Release Form
Event: Date(s) of Event:
Name: Chapter:
Address: Birthdate:
City: State:             Zip:
Home Phone: Other Phone:
Health/Accident Insurance Info:
Company: Policy #:
Physician: Phone:
Special Medications/Health Problems/Allergies:
In the event of injury or illness to my son/daughter/ward, I hereby authorize and direct Howard K. Smith, Sr. or an adult directed by him to secure medical treatment, including hospitalization, thereby authorizing any said persons to sign any consent thereto as if I was personally present. Furthermore, I agree, on notification from the DeMolay staff, to pick up my son/daughter/ward if in the opinion of the staff it is necessary that he/she be removed from the activity site. I have read and throughly understand the attached rules and agree to abide by them.
Signed: Signed:
Participant Parent or Guardian

Event Rules:

Conclave Rules:

Other Remarks as appropriate may be written below: