...: medical form

-Fact participant –

-medical form–

Name :

First name :

Date of birth :

Adress :

Country :

Phone :

E-mail :

medical information

allergy :

treatment :

medical problem :

Family information

Name and first name of mother :

Name and first name of father :

Phone :

authorization

I ………………………………………………parent (legal guardian) of………………………..………., affirm hereby :

O to have declared the exact information provided on this form

O to allow my child to participate in the activities of the MJC

O to authorizes the Director of the stay to take all necessary measures by the state of the child : medical
treatment, hospitalization, surgery, ...

Date :

signature :

...