General Release And Authorization Form (Page 2 of 2) in pdf

General Release And Authorization Form Page 2

PARTICIPANT HEALTH AND MEDICAL INFORMATION

Participant Name ____________________________________Date of Birth ___________________

Church _________________________________Group Leader Name _________________________

The following information is required to secure medical treatment should it become necessary. Please

answer all questions completely.

List any medications you are CURRENTLY taking:

________________________________________________________________________________________

__________________________________________________________________________

List any medical conditions for which you are CURRENTLY being treated:

________________________________________________________________________________________

__________________________________________________________________________

List any medications or other substances to which you are allergic:

________________________________________________________________________________________

__________________________________________________________________________

Date of last Tetanus Shot ___________________

HEALTH INSURANCE INFORMATION

Health Insurance Carrier ____________________________ Phone No. (____)______________

Insurance Policy Number ______________________________________________

EMERGENCY CONTACT INFORMATION

Name _________________________

Relationship ___________________________

Day Phone _____________________

Evening Phone _________________________

PLEASE BRING TWO COPIES WITH YOU TO THE PROJECT

(Do not mail this form to our office)

General Release And Authorization Form Page 2