TCBA Staff Registration and Medical Release Form

"*" indicates required fields

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.
This field is for validation purposes and should be left unchanged.