Medical Release

2026 Blossomtime Medical Information
for ALL Blossomtime Participants

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Contestant Name

Date of Birth (YYYY-MM-DD)

Street Address (not a P.O. Box)

City

State

Zip Code

Contestant Email Address

Contestant Cell Phone Number

Mother/Guardian’s Name

Mother/Guardian’s Email

Mother/Guardian’s Address (Street Address, City, State, Zip)

Mother/Guardian’s Cell Phone Number

Mother/Guardian’s Work Phone Number

Mother/Guardian’s Home Phone Number

Father/Guardian’s Name

Father/Guardian’s Email

Father/Guardian’s Address (Street Address, City, State, Zip)

Father/Guardian’s Cell Phone Number

Father/Guardian’s Work Phone Number

Father/Guardian’s Home Phone Number

Are you Currently under a Physician’s Care?

If Yes, List Reason

Do You Take Medication Daily?

If Yes, List Medication(s)

Are you allergic to any food or have any special dietary needs (vegan, etc)?

Are you allergic to any medications?

If Yes, Please List

Any medical issue(s) we should be aware of:

Name of Health Insurance

Group #

Name of Physician

Physician Phone number

Physician Address (Street Address, City, State, Zip)

Name of Dentist

Dentist Phone number

Dentist Address (Street Address, City, State, Zip)

CONSENT FOR MEDICAL/DENTAL/SURGICAL TREATMENT

Name of Patient , minor. Permission is hereby given to this hospital, its physicians and its nursing staff to administer any treatment, diagnostic, therapeutic, or to administer such surgical procedures as may be deemed necessary or advisable in the diagnosis and treatment as condition warrants, and to release information as may be necessary for hospital claims.

Electronic Signature of Parent/Legal Guardian

Electronic Signature of Witness

Relationship to Patient

Date (YYYY-MM-DD)