MS Delta Participant Form

MS Delta Information and Release Form

Name of Team/Group*
Today's Date*
MM slash DD slash YYYY
Gender*
- Male
- Female
Name*
First Middle Last Suffix
The name you go by*
Birth Date*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Work Phone
Home Phone
Cell Phone*
Email*
My Occupation*
Skills and Abilities*
Professional Titles
ex. MD, DDS, RPh, Rev, RN, LPN
Post Photo (JPEG format) of Professional License*
Accepted file types: jpg, jpeg, png, gif.
*You must also take a hard copy of this with you to work in the clinic.
Post Photo (JPEG format) of Professional Diploma*
Accepted file types: jpg, jpeg, png, gif.
*You must also take a hard copy of this with you to work in the clinic.
Medical and Emergency Contact Information
Emergency Contact*
Relationship to you*
Contact Phone*
Contact Email*
Medications
What medications do you regularly take, prescription or over the counter?
Medical Conditions
Do you have any medical conditions, medical problems or recent surgeries? If so, describe them.
Do you have any allergies that we should be aware of?*
Name of Physician*
Physician Phone*
Are you 18 or older?*
- Yes
- No
Are you Married?*
- Yes
- No
Signature*
Understand that by signing this form you are stating that all the information you have given on this for is true and that you agree with the RELEASE, WAIVER OF LIABILITY, AND ARBITRATION AGREEMENT.
Date Signed*
MM slash DD slash YYYY
IF YOU ARE UNDER 18 YEARS OLD, you are considered a minor and this release must be signed by BOTH PARENTS and/or GUARDIANS (and spouse, if minor is married). (Skip this section if you are 21 or older.)
- Please check if only one parent is signing and you have sole custody or if the other parent is deceased.
Name(s) of Parent(s) or legal Guardian(s)*
Signature of Minor's Parent/Guardian #1*
Signature of Minor's Parent/Guardian #2*
Signature of Minor's Spouse if Married*

MS Delta Information and Release Form

Medical and Emergency Contact Information

Recent Children

Sponsor a Child

Sponsor a Child