Rolling Hills United Methodist Church

MEDICAL RELEASE AND WAIVER OF LIABILITY
Please take a moment and fill in the information below. When all the fields have been filled in, you can press the continue button and that will give you a printable form, ready for your parent to read and sign. You will not be permitted on any trip without the form! Items in RED are required
*Trip:
*Minors First Name:
*Minors Last Name:
Sex:
*Parent/Guardian:
*Birthdate:
*Home Phone:
Work phone:
Cell Phone:
Insurance Company:
Policy #:
Physicians Name:
Physicians Phone:
Any Know Allergies?:
Last Tetanus Shot:
Other Medical Information: