Release and Liability Form

First Name

Last Name

Home Phone

Cell Phone

Address

City

State

Country

Emergency Contact

Emergency Contact First Name

Emergency Contact Last Name

Relationship

Emergency Contact Phone Number

Medical Information

Any past or current medical history that could require medical care while working on a GO Overflow mission? (i.e., diabetes, seizures, allergic reactions, etc.

Are you taking any medication(s)? *

If so, please list:

List any known allergies and reactions:

Provide any relevant past surgical history:

Personal Physician Information

Name of Personal Physician

Physician Phone Number *

Medical Insurance Information

Company Name

Phone Number

Group Policy Numbers

Member ID:

Release and Waiver of Liability

CLICK HERE TO READ THE RELEASE AND WAIVER OF LIABILITY. THIS IS A LEGAL DOCUMENT THAT AFFECTS YOUR LEGAL RIGHTS.

Signature (If 18 or older)

To be signed by Parent or Guardian of Volunteer if Under Age 18