2024 NBC Medical Release Form

Full Name

First NameMiddle NameLast Name

Birthdate

Date

Gender

Address

Street Address

Street Address Line 2

CityState

Zip Code

What phone numbers do you regularly use?

Cell Phone

Format: (000) 000-0000.

Work Phone

Format: (000) 000-0000.

Home Phone

Format: (000) 000-0000.

Email Address

Emergency Contact Name

First NameLast Name

Relationship

e.g. neighbor, friend, aunt, grandfather, etc.

What phone numbers does your emergency contact regularly use?

Home Number

Format: (000) 000-0000.

Cell Number

Format: (000) 000-0000.

Work Number

Format: (000) 000-0000.

Secondary Contact Name

First NameLast Name

Relationship

e.g. neighbor, friend, aunt, grandfather, etc.

What phone numbers does your emergency contact regularly use?

Home Number

Format: (000) 000-0000.

Cell Number

Format: (000) 000-0000.

Work Number

Format: (000) 000-0000.

Insurance Carrier

Policy Number

Doctor's Name

First NameLast Name

Doctor's Phone Number

Format: (000) 000-0000.

Health Issues

if none, enter "N/A"

Known Allergies

if none, enter "N/A"

Medications (name/dosage/purpose)

if none, enter "N/A"

Last Tetanus Booster

Date

Additional Instructions

Agreement

I, the undersigned person, do hereby authorize Neighborhood Bible Church as agent for the hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of, any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of any hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority of power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnoses, treatment or hospital care which a physician, meeting the requirements of this authorization, may in the exercise of her/his best judgment, deem advisable. The authorization is given pursuant to the provisions of Section 56.11 of the Civil Code of California. This authorization shall remain effective until December 31, 2020 unless sooner revoked in writing delivered to said agent(s).

Signature

Date

2025 Medical Release Form - Adult

Personal Information

Emergency Contact Information

Medical Information