2024 NBC Medical Release Form

2025 Medical Release Form - Adult
Personal Information
Full Name

First NameMiddle NameLast Name
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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 Information
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.
Medical Information
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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

2025 Medical Release Form - Adult

Personal Information

Emergency Contact Information

Medical Information