Ohio Medical Release Form 1
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Mid-Ohio Valley Work Camp: Medical Release Form
Name:___________________________________ Congregation:_____________________________
Home Address: _____________________________________________________________________
Gender:

□ Male

□ Female

Birthdate: ____________________________

Custodial Parent/Guardian: ____________________________________________________________
Address: ____________________________________________________________
Home Phone: ___________________

Work:__________________ Cell: ____________________

Second Emergency Contact: ______________________________

Phone:_____________________

Relationship: ______________________________

Insurance Information:
Is the Participant covered by medical/hospital Insurance?
Group # ___________________________

□ Yes

□ No

Carrier or Plan Name:_____________________

Allergies or Medical Conditions/surgeries: (List all known, including Food, and medical management
if any):
___________________________________
_____________________