Medical Release Of Liability Form
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Medical Release and Liability Form Central Texas Conference Young People’s Ministries Events Name of Participant Name of Legal Guardian/s Address, City, State, Zip Home Phone () Work/Cell Phone () Age Birthday School E-mail Date of Last Tetanus Shot Functions and Activities I understand that participating in programs, recreation and other activities of Central Texas Conference of the United Methodist Church is a privilege.. Insurance information Carrier Policy Number Policy Holder Name Carrier Phone Number Page 1 of a 2 page document Emergency Contacts Medical Doctor Phone Number Name 1 Relation Home Phone Work/Cell Phone Name 2 Relation Home Phone Work/Cell Phone Medical History (Include special medical needs or concerns such as asthma, allergies, conditions, medications, etc.) Special Dietary needs
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