Common Contracts
1 similar Participation Agreement and General Release contracts
Participation Agreement and General ReleaseParticipation Agreement and General Release • February 22nd, 2023
Intern/Observer/Participant Information Name Date of Birth Sex Parent’s/Guardian’s Name (if under 18 years of age) Parent’s/Guardian’s Name (if under 18 years of age) Home Phone ([ ]) Work/Cell Phone ([ ]) Home Phone ([ ]) Work/Cell Phone ([ ]) Address Address City, ST ZIP Code City, ST ZIP Code Emergency Contacts Primary Emergency Contact Secondary Emergency Contact Home Phone ([ ]) Work/Cell Phone ([ ]) Home Phone ([ ]) Work/Cell Phone ([ ]) Medical Information and Emergency Treatment Authorization for Participants ANYONE REQUIRING IMMEDIATE MEDICAL ATTENTION WILL BE TAKEN TO THE MOST APPROPRIATE MEDICAL FACILITY. Primary Care Physician’s Name Phone Number Insurance Company Policy Number In the case of an emergency, I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics and waive my right to informed consent of treatment. I acknowledge th
