TCBA Staff Registration and Medical Release Form

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Untitled
T-Shirt Adult Sizes (select one):

Contact Details

Name*
DOB*
Address*

Emergency Contact Information

Name*

Insurance Information

Policy Holder's Name

Medical History/Allergies

Asthma*
Diabetes*
Heart Trouble*
Fainting Spells*
Convulsions*
Immunizations up to date?*

Medical Release

Consent*
Date
Date
Any person age 18 or older involved with supervision of minors must complete a confidential volunteer application and sign a background check release form. A link to the background check will be emailed to you upon receipt of this form. Please complete background check promptly.