2025 Medical Release Form - Adult
Personal Information
Full Name
*
First Name
Middle Name
Last Name
Birthdate
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Month
-
Day
Year
Date
Gender
*
Male
Female
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
Idaho
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Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
What phone numbers do you regularly use?
*
Cell
Work
Home
Cell Phone
*
Work Phone
*
Home Phone
*
Email Address
*
Emergency Contact Information
Emergency Contact Name
*
First Name
Last Name
Relationship
*
e.g. neighbor, friend, aunt, grandfather, etc.
What phone numbers does your emergency contact regularly use?
*
Home
Cell
Work
Home Number
*
Cell Number
*
Work Number
*
Secondary Contact Name
*
First Name
Last Name
Relationship
*
e.g. neighbor, friend, aunt, grandfather, etc.
What phone numbers does your emergency contact regularly use?
*
Home
Cell
Work
Home Number
*
Cell Number
*
Work Number
*
Medical Information
Insurance Carrier
*
Policy Number
*
Doctor's Name
First Name
Last Name
Doctor's Phone Number
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
*
-
Month
-
Day
Year
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
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Month
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Day
Year
Date
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