VOLUNTEER SERVICE RELEASE FORM  

I have Medical Insurance: *
Name *
Name
Address *
Address
include both PO Boxes and Physical Address if necessary.
Phone - Home *
Phone - Home
Phone - Mobile
Phone - Mobile
Marital Status *
In Case of Emercency
Name 1 *
Name 1
Primary Phone *
Primary Phone
Phone - Other *
Phone - Other
Address 1 *
Address 1
Please check any of the following medical conditions that you currently have or have had ay anytime in the past: *
DIGITAL SIGNATURE (IF UNDER AGE 18 - YOU PARENT / LEGAL GAURDIAN MUST SIGN BELOW) *
By writing my first and last name below, I affirm my agreement to the following Release of Liability - as if I was placing my signature below. I hereby certify that this information is an accurate representation of my medical history. Should any changes occur related to my medical and / or mental condition, I will notify Nehemiah Projects immediately. In the event that I need emergency care and am unable to give my consent at that time, I hereby authorize any member of the Nehemiah Projects Leadership Team to authorize any emergency medical attention that is needed.