Medical and Media Consent Release Form Name*FirstLast Birth Date* Street Address* City* Zip Code* Email* Parent/Guardian Name*FirstLast Parent/Guardian Phone* Area Code - Phone Number Parent/Guardian Name(2)FirstLast Parent/Guardian Phone(2) Area Code - Phone Number Insurance Carrier* Insurance Carrier Phone Area Code - Phone Number Family Doctor* Family Doctor Phone* Area Code - Phone Number Please list any allergies or medical concerns* Check any that apply:Contacts?Glasses?Braces? Please list current medications*Emergency Contact other than parent/guardian: Emergency Contact NameFirstLast Emergency Contact Phone* Area Code - Phone Number RelationshipIf Minor, in case of emergency, I understand that every effort will be made to contact me. In the event that I cannot be reached, I hereby give permission to the medical professionals selected by the group leader to treat my child as necessary. By electronically submitting this form, I affirm that the above information is correct.Media Consent: Do you give permission for the above named person's photos to be taken and used on EPC website, social media, and other media publications?*YesNoThis form is valid for one year from submission date.SubmitReset
If Minor, in case of emergency, I understand that every effort will be made to contact me. In the event that I cannot be reached, I hereby give permission to the medical professionals selected by the group leader to treat my child as necessary. By electronically submitting this form, I affirm that the above information is correct.
This form is valid for one year from submission date.
