Illinois Medical Release Form 1Illinois Medical Release Form 1
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MEDICAL / LIABILITY RELEASE and CONDUCT CODE AGREEMENT FORM
Due to legal restrictions, it is necessary that all students, chaperones, and HOSA Advisors complete
this form as a prerequisite for eligibility to attend the State HOSA Conference. Chapter Advisor,
please make a copy for your files and mail the originals to the State Conference Manager.
PLEASE TYPE OR PRINT ALL INFORMATION
Name _________________________________________________________________________
(Circle title)

Advisor

Alumni

Chaperone

Student

Professional

Home Address __________________________________ Home # (_____)________________
City

___________________________________________ Zip ____________________

Parent/Guardian's Name ___________________________________________________________
(If appropriate)

Father Work # (_____)______________________ Mother Work #(_____)___________________
Additional Phone #(____)__________________________________________________________
Alternate Contact ___________________________