Medical Release Form

Download a blank fillable Medical Release Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Medical Release Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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Medical Release Form
This form must be signed and notarized.
Name of Church:_______________________ City/State:________________________
Name:______________________________ Social Security #:____________________
Birthdate:____/____/______ Age:____ Sex (M/F):_____
Address:_______________________________________________________________
City:_________________________ State:____________________ Zip:_____________
Parent/Guardian:________________________________________________________
Home Phone:(___)________________Work Phone:(___)________________________
Secondary contact to notify in event of emergency:_____________________________
Their relationship to you:__________________ Their phone:(___)_________________
Please supply ALL of the following information. Attach a copy of your insurance card.
Medical Insurance Co.:___________________ Group#________ Policy#:___________
Company’s address:____________________ Company’s Phone:(___)_____________
City:________________________ State:____________________ Zip:_____________
Family Physician’s Name:_______________________ Phone:(___)________________
Physical Limitations (Asthma, diabetes, allergies, etc.), and/or special instructions
(Allergic to certain meds, rare blood type, wears contact lenses, etc.):
______________________________________________________________________
______________________________________________________________________
List ALL medication taken on a regular basis and/or any brought with (Prescription meds
MUST have pharmacy label and doctor’s name:
______________________________________________________________________
______________________________________________________________________
List all operations/serious injuries and dates within the past five (5) years:
______________________________________________________________________
______________________________________________________________________
Date of last Tetanus Shot:_________________________________________________

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