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CTVN TEAM MEMBER MEDICAL RELEASE
THIS FORM MUST BE COMPLETED AND APPROPRIATELY SIGNED BY ALL WEEKEND PARTICIPANTS UNDER THE AGE OF 18 PRIOR TO COMMENCEMENT OF WEEKEND ACTIVITIES. A NEW FORM MUST BE COMPLETED FOR EACH WEEKEND IN WHICH THE TEAM MEMBER SERVES AND WILL BE HELD BY THE VIDA NUEVA COUNCIL REPRESENTATIVE DURING THE COURSE OF THE WEEKEND.
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Email
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Your email
NAME OF TEAM MEMBER (FIRST AND LAST NAME)
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Your answer
PLEASE INDICATE ANY AND ALL MEDICAL ALLERGIES, MEDICATIONS BEING TAKEN, MEDICAL PROBLEMS OR CONDITIONS, SPECIAL DIETS (FOR VALID, DIAGNOSED MEDICAL CONDITIONS), OR ANY OTHER PERTINENT INFORMATION
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Your answer
TEAM MEMBER MEDICAL INSURANCE COMPANY
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Your answer
GROUP #
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Your answer
MEMBER #
Your answer
Father's Name (First and Last Name)
Your answer
Father's Cell Phone Number (Example: 615-xxx-xxxx)
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Your answer
Mother's Name (First and Last Name)
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Your answer
Mother's Cell Phone Number (Example: 615-xxx-xxxx)
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Your answer
Emergency Contact Name (First and Last Name)
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Your answer
Emergency Contact Phone Number (Example 615-xxx-xxxx)
Your answer
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