Medical Release Form

Please complete this Emergency Medical Release Form, then click the "Submit" button at the bottom.

Thank you for being ready to be a buddy with our amazing Rise & Nye's team members.

Name*
First Middle Last
Birthday*
MM slash DD slash YYYY
Address*
Address Line 2 City State ZIP Code
Email*
Phone*
Parent / Guardian*
Physician's Name*
Preferred Hospital
Allergies to Medications*
Current Medications*
Emergency Contact Name*
First Last
Emergency Contact Phone*
Emergency Contact Name*
First Last
Emergency Contact Phone*
Consent

In the event of a medical emergency and aid / treatment is required due to illness or injury, I authorize Rise & Nye's to secure medical treatment and transportation (if needed) and to release the provided medical information upon request to the authorized individual or agency involved in the medical emergency treatment.
Signature*
Minor Signature
Date
MM slash DD slash YYYY