Medical Release Form

Please complete this Emergency Medical Release Form, then click the "Submit" button at the bottom.

Thank you for being ready to be a buddy with our amazing Rise Up Cafe team members.

Name*
First Middle Last
Birthday*
MM slash DD slash YYYY
Address*
Address Line 2 City State ZIP Code
Email*
Phone*
Parent / Guardian*
Physician's Name*
Preferred Hospital
Allergies to Medications*
Current Medications*
Emergency Contact Name*
First Last
Emergency Contact Phone*
Emergency Contact Name*
First Last
Emergency Contact Phone*
Consent

In the event of a medical emergency and aid / treatment is required due to illness or injury, I authorize Rise Up Cafe to secure medical treatment and transportation (if needed) and to release the provided medical information upon request to the authorized individual or agency involved in the medical emergency treatment.
Signature*
Minor Signature
Date
MM slash DD slash YYYY