Medical Release Form | Come before Winter

Medical Release Form

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
List any health issues that might be of value to CbW in the event that you require emergency care during your time with us (e.g., diabetic concerns):
Current medications and conditions for which prescribed: (i.e. Benicar for blood pressure)
Due to allergies, I am required to carry an EpiPen*
- Yes
- No
If “Yes,” I will keep it with me in my tote bag at all times.*
Please initial
Permission to treat this individual in case of emergency*
- Yes
- No
Emergency Contact Name*
First Last
Emergency Contact Phone number*
Relationship to emergency contact*

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P.O. Box 323
Round Rock, TX 78680

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