2023-2024 Adult Medical Release Form
Please complete this form in its entirety. DO NOT FORGET TO HIT THE SUBMIT BUTTON AFTER CLICKING LINK AT BOTTOM FOR VERIFIED ESIGNATURE.
Name
*
Gender
*
Please select one option.
Male
Female
Select Option
Male
Female
Birthdate
*
Age
*
Email
*
This address will receive a confirmation email
Phone
*
Address
*
--
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Emergency Contact Name (1)
*
Emergency Contact Phone (1)
*
Emergency Contact Name (2)
Emergency Contact Phone (2)
Allergies, Medical, & Special Needs
*
Please select one option.
YES
NO
Please list any allergies, dietary restrictions, medical or health problems that would affect his/her participation in any activities:
List any medications taken:
Name of participant's physician and any other physician who can be consulted in the event of emergency or medical problems involving this participant:
*
Physician Address
*
Physician Phone
*
Insurance Information
Name of Insurance Company
*
Insurance Address
*
Name of Primary Policy Holder
*
Policy Number
*
Phone Number of Insurance Company
*
Medical Release
***PLEASE BE SURE TO RETURN TO THIS PAGE AND HIT "SUBMIT" BUTTON TO FINALIZE SUBMISSION OF FORM***
Please use this link to esign medical release form (required for participation):
CLICK LINK:
eSignature for Medical Release Form
Submit
Description
Please complete this form in its entirety. DO NOT FORGET TO HIT THE SUBMIT BUTTON AFTER CLICKING LINK AT BOTTOM FOR VERIFIED ESIGNATURE.
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