2017 Medical/Discipline/Medical Release Form
This form is required for any participant on any church sponsored trip, function or event. This form will be used for all trips or events during that particular year. If there are changes throughout the year, it is the participants responsibility to complete an updated form
Email address *
Participant's Last Name *
Your answer
Participant's First Name *
Your answer
Birth Date *
MM
/
DD
/
YYYY
Age *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Contact Phone Number *
Your answer
Cell Phone Number (If Different Than Contact Number)
Your answer
May We Contact You Via Text Message *
Email Address *
Your answer
If Participant Is Under 18 Years Of Age, Please Fill Out The Information Below
Father/Guardian's Name *
Your answer
Father/Guardian's Work Phone Number *
Your answer
Father/Guardian's Cell Phone Number *
Your answer
Mother/Guardian's Name *
Your answer
Mother/Guardian's Work Phone Number *
Your answer
Mother/Guardian's Cell Phone Number *
Your answer
Please Provide The Following Information For Emergency Contacts
EMERGENCY CONTACT 1
Name *
Your answer
Relationship *
Your answer
Contact Phone Number *
Your answer
EMERGENCY CONTACT 2
Name *
Your answer
Relationship *
Your answer
Contact Phone Number *
Your answer
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