MEDICAL RELEASE

Name of Participant *
Name of Participant
Date of Birth of Participant *
Date of Birth of Participant
Select "Yes, I do," if you or the minor participating in the program has any conditions which might be a safety concern, such as allergies, asthma, heart conditions, anxiety, or other potential concerns.
Emergency Contact Person *
Emergency Contact Person
Phone of Emergency Contact *
Phone of Emergency Contact
Secondary Phone Number
Secondary Phone Number
Please check the following preconditions which may apply to you. *
SIGNATURE of participants over the age of 18, or Legal Guardian if participant is under the age of 18. By entering my name into this form, I sign that the above information is true. *
SIGNATURE of participants over the age of 18, or Legal Guardian if participant is under the age of 18. By entering my name into this form, I sign that the above information is true.