Team Permission | Awakening of Bryan Ohio

Team Member Permission Slip & Medical Information

Team Member's First Name

Team Member's Last Name

Team Member's Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

Phone Number

Parent's First Name

Parent's Last Name

Parent's Phone number

Relationship

Parent's Email

Parent's First Name

Parent's Last Name

Parent's Phone number

Relationship

Additional Emergency Contact First Name

Additional Emergency Contact Last Name

Phone number

Relationship

Allergies: (to medications, bug bites, foods, etc.)

Medications presently taking and schedule

Insurance carrier

Group number

Account number

Preferred medical facility

I, , give my permission for my son/daughter, , to participate in the Awakening weekend. I also give permission to the director(s) of the Bryan Awakening Community, to seek medical attention for my son/daughter if deemed necessary. In the event of an emergency, I will be notified as soon as
possible at the above-mentioned phone number(s).

Today's date

I consent to have this website store my submitted information for the use described in the form.

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