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Immunization record (required)

DPTTDPoliomyelitisMeaslesRubellaOtherNone

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Medical history (required)

AsthmaBroken bonesBronchitisChicken poxConvulsionsDiabetesFaintingFrequent coldsFrequent sore throatGerman measlesHeart ProblemsKidney troubleMeaslesMumpsPoison Ivy/oakRespiratory difficultiesRheumatic feverSeizuresSinusitisStomach upsetsTuberculosisNone

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MEDICAL RELEASE SIGNATURE

My child, , is under eighteen years of age and has my permission to attend the Leadership Training Institute of America National conference. ,

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By submitting this form, I authorize such medical procedures as are deemed necessary, in case of an emergency, to be performed on the above student by, or at the discretion of the LTI of America Medical Staff and/or Director.