Health Information and Release Form | Miss USA

Health Information & Release Form

HEALTH INFORMATION & RELEASE FORM

Select Pageant

Delegate First Name

Delegate Last Name

Delegate Title

Delegate Email

Confirm Email

Delegate Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

EMERGENCY CONTACT DETAILS

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone/Mobile

MEDICAL INFORMATION

Current Physician First Name

Current Physician Last Name

Current Physician Phone/Mobile

List any medications currently taking:

List any allergies to medications (e.g. penicillin)

MEDICAL INSURANCE

Do You Have Health Insurance?

Insurance Company

Insurance Company Address

Street Adress

Street Address Line 2

City

State

Zip Code

Country

Insurance Policy Number

Group Number

Contestant of Parental/Guardian Consent for Medical Diagnosis, Treatment, and Billing of Insurance

(Parental signature needed for minors and contestants who are on their parents Insurance)

I hereby consent to allow A Blaize Productions LLC and staff to select a hospital, clinic, or other medical facility that shall be authorized to diagnose and treat the contestant named below for any medical problem that may occur during the state pageant competition. In addition, I hereby release A Blaize Productions LLC and staff from all liability therefrom and give permission to those granting services to bill my Insurance company listed for any and all services rendered. In the event that the contestant does not have medical insurance or the medical provider does not accept her specific insurance, payment responsibility is that of the parent/guardian.

Consent for treatment (Required)

Delegate or Parent/Guardian must check box below

Parent/Guardian Name (If Applicable)

Last Name

Health Information & Release Form

By submitting this form, I confirm that the health information provided is true and complete to the best of my knowledge. I understand that participation in pageant activities involves inherent risks, and I voluntarily assume full responsibility for my participation. I hereby release and hold harmless A Blaize Productions, the Miss USA Organization, and all affiliated staff, venues, and partners from any liability for injury, illness, loss, or damages arising from my participation, except in cases of gross negligence.

If under 18, a parent or legal guardian acknowledges and agrees to these terms on my behalf.