Medical form

MEDICAL WAIVER

* Indicates required field

Name *

First

Last

Cell Number *

Email *

Emergency Contacts

Primary Emergency Contact *

First

Last

Cell Number *

Secondary Emergency Contact *

First

Last

Cell Number *

Medical Information

Hospital Preference *

Allergies/Special Health Considerations *

Physician's Name *

Consent

I authorize 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. I release [Organization]and individuals from liability in case of accident during activities *

Yes

Submit