Medical Release Form – The Rock Texas

Parent/Legal Guardian’s Name: *

Address *

Address Line 1

City

State

Zip Code

Mobile Phone *

Home Phone

Work Phone

Other Phone #

Child's Name *

Medical History *

Emergency Contact *

Relationship to Child *

Emergency Contact Phone Number #1 *

Emergency Contact #2

Emergency Contact #2 Relationship to Child

Emergency Contact Phone Number #2

Physician’s Name *

Physician's Address *

Address Line 1

City

State

Zip Code

Physician's Phone *

Dentist's Name *

Dentist's Address *

Address Line 1

City

State

Zip Code

Dentist's Phone *

Primary Insurance Company:

Primary Insurance Company Billing Address

Address Line 1

City

State

Zip Code

Policy Holder’s Name:

Policy Holder’s Address

Address Line 1

City

State

Zip Code

Policy Holder’s Relationship to Child

ID#

Group/Policy #

Please upload a copy of your driver’s license and front & back of your insurance card. *

Click or drag files to this area to upload. You can upload up to 3 files.

Commission Expires:____________________________________