FLORIDA SKILL USA MEDICAL RELEASE FORM
   REGIONAL CONTEST    STATE CONTEST

Contest Number:                    Contest Name ____________________________________________

Contest Number:                    Contest Name ____________________________________________


    Advisor Guest Delegate Model Alternate Contestant
Contestant: Secondary Post Secondary

Name (First Last) as it will appear on name badge:

__

Name of SkillsUSA Advisor

____

Home Address School
City                                         ,FL            Zip School Address
Home Telephone (           )  City                                         ,FL       Zip
Age ____ Date of Birth ___/____/____    M F  School Telephone (           )

EMERGENCY INFORMATION
Emergency contact person:                            Telephone (           )
Address of contact person:                                                  City                                         ,FL       Zip
Physician's Name:  Physician's Phone (           )
Insurance Company  Insurance Plan ID #

1- Do you have any known allergies? YES No - If yes, please list on back of form

2- Are you taking medication YES No - If yes, please list what kind: on back of form

3 - Do you have a history of allergies, heart condition, diabetes, asthma, epilepsy, rheumatic fever,
or other existing medical conditions? YES No - If yes, please explain on back of form

CHECK HERE IF YOU ARE OVER 18 AND CAN SIGN FOR YOURSELF

Having read and understood completely the Personal Liability and Medical Release, the Code of Conduct,
and the Violations and Penalties agreements on the other side of this form, I, by signing below,
do hereby agree to abide by these in their entirety and completely release FLORIDA SkillsUSA, Inc.

Signature of Participant ___________________________________________ Date _____/_____/_____

Signature of Parent or Guardian _____________________________________ Date _____/_____/_____
(Mandatory if under age 18)
The Florida SkillsUSA is a resource and support organization that does not select, control or supervise local chapter or
individual member activities except as expressly provided in the Florida SkillsUSA Constitution and Bylaws.