Page 1

Emergency / Medical Form

First Name:

Last Name:

Email:

Emergency contact full name:

Emergency contact phone number:

Please list any health conditions you may have:

Please list any medications you may be taking:

Please list any allergies you may have:

Please list any health-related restrictions / limitations:

Are you first aid / CPR certified?

YesNo

Contact ID

Page 2

Photo / Video Release

The BTS Center will be documenting this event with photography, videography and audio recordings, which may be used for promotional and educational purposes.

I grant The BTS Center permission to use such materials that include photographic or video /audio recordings of me.I do not grant such permission.

Full Name (typing your name in this box qualifies as your signature):

Date: