Nonprofit Medical Consent and Release Form
Participant Name
Date of Birth
Parent/Guardian Name (if under 18)
Address
Phone Number
Email
Emergency Contact
Emergency Contact Name
Emergency Contact Phone
Medical Information
Allergies, Medical Conditions, or Medications
Primary Physician Name
Physician Phone Number
Consent and Release
I hereby give consent for medical treatment in the event of an emergency and release the nonprofit organization from any liability or claim resulting from such treatment.
Participant or Parent/Guardian Signature
Date