Medical Release Form
Grace Community Bible Church
1045 US 41 Bypass S.
Venice, FL 34285

Medical Release Form / Permission to Treat
This Release form is considered valid for any event attended with Grace Community Bible Church between 7/1/2017 - 7/1/2018

First Name *
Your answer
Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Age *
Your answer
Gender *
Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Emergency Contact Information
Parent/Guardian *
Your answer
Primary Phone *
Your answer
Secondary Phone
Your answer
Secondary Contact *
Your answer
Primary Phone *
Your answer
Secondary Phone
Your answer
INSURANCE INFORMATION
Company Name
Your answer
Group #
Your answer
Policy #
Your answer
Cardholder Name
Your answer
Relationship to Cardholder
Your answer
Insurance Company Address
Your answer
Insurance Company Phone
Your answer
PERSONAL MEDICAL INFORMATION
Physician Name
Your answer
Physician Phone Number
Your answer
Physical Limitations (Asthma, diabetes, allergies, etc.), and/or Special Instructions (Allergic to certain medication(s), rare blood type, wears contact lenses, etc.)
Your answer
MEDICATION
List ALL medication taken on a regular basis and/or any brought with you. (Prescription medication(s) MUST have a pharmacy label and name of doctor.)
Your answer
List all operations/serious injuries and dates within the past five (5) years:
Your answer
Next
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