HOUSE BUILD PARTICIPATION FORM

TRIP INFO
Trip Date *
Trip Date
REGISTRANT INFO
Name *
Name
Address *
Address
Phone *
Phone
Date of Birth *
Date of Birth
(If none, please put N/A)
RELEASE OF LIABILITY/CONSENT
DO YOU AGREE TO THE ABOVE STATEMENT?
DO YOU AGREE TO THE ABOVE STATEMENT?
DO YOU AGREE TO THE ABOVE STATEMENT?
DO YOU AGREE TO THE ABOVE STATEMENT?
DO YOU AGREE TO THE ABOVE STATEMENT?
Date *
Date
MEDICAL RELEASE FORM
Registrant Name *
Registrant Name
Doctor's Phone *
Doctor's Phone
(If none, please put N/A)
(If none, please put N/A)
(If none, please put N/A)
Medical Problems:
EMERGENCY PHONE NUMBERS (Please list 2 including name and relationship to applicant)
Name *
Name
Phone *
Phone
Name *
Name
Phone *
Phone
CONSENT FOR EMERGENCY MEDICAL TREATMENT
Please Note: It is understood that every attempt will be made to notify the volunteer’s emergency support system before treatment is given.
DO YOU AGREE TO THE ABOVE STATEMENT?
Date *
Date