Medical Release Form for Conference Drivers

Church in Round Rock Medical Release Form
Conference Participant Information
Date*

MonthDayYear
Date
Name of young person*

First NameLast Name
Parent/Guardian Contact Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone numberFormat: (000) 000-0000.
Email*
example@example.com
Family Physician (enter N/A if none)*
Phone Number (enter 999-999-9999 if none)*
Use 999-999-9999 if noneFormat: (000) 000-0000.
Insurance Company (enter N/A if none)*
Policy Number (enter N/A if none)*
Group Number (enter N/A if none)*
Current medication, allergies, or health problems (enter N/A if none)*
By signing below, I, the Parent or Guardian of the above named Participant, authorize the bearer of this document to obtain all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. I also accept full responsibility for the payment of any expenses incurred from such medical and/or emergency care.
Adult participant or parent/guardian’s signature*

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Church in Round Rock Medical Release Form