CTVN TEAM MEMBER MEDICAL RELEASE
THIS FORM MUST BE COMPLETED AND APPROPRIATELY SIGNED BY ALL WEEKEND PARTICIPANTS UNDER THE AGE OF 18 PRIOR TO COMMENCEMENT OF WEEKEND ACTIVITIES. A NEW FORM MUST BE COMPLETED FOR EACH WEEKEND IN WHICH THE TEAM MEMBER SERVES AND WILL BE HELD BY THE VIDA NUEVA COUNCIL REPRESENTATIVE DURING THE COURSE OF THE WEEKEND.
Email address *
NAME OF TEAM MEMBER (FIRST AND LAST NAME) *
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PLEASE INDICATE ANY AND ALL MEDICAL ALLERGIES, MEDICATIONS BEING TAKEN, MEDICAL PROBLEMS OR CONDITIONS, SPECIAL DIETS (FOR VALID, DIAGNOSED MEDICAL CONDITIONS), OR ANY OTHER PERTINENT INFORMATION *
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TEAM MEMBER MEDICAL INSURANCE COMPANY *
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GROUP # *
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MEMBER #
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Father's Name (First and Last Name)
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Father's Cell Phone Number (Example: 615-xxx-xxxx) *
Your answer
Mother's Name (First and Last Name) *
Your answer
Mother's Cell Phone Number (Example: 615-xxx-xxxx) *
Your answer
Emergency Contact Name (First and Last Name) *
Your answer
Emergency Contact Phone Number (Example 615-xxx-xxxx)
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