Medical Waiver Form
Please complete the following medical waiver form.
Participant's Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Medical Condition(s)
Medications
Treatment Plan
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone
Please enter a valid phone number.
I acknowledge that participating in the medical procedure/activity involves certain risks and that I release the health professional/organization from any liability for injury or harm.
*
I agree
Participant's Signature
*
Submit
Should be Empty: