Adult

Work Entry

Adult Medical Hold Harmless Form

Medical Hold Harmless Forms provide insurance and legal information in case of an emergency, and is required for kids, students and adults to participate in certain activities at Fairhaven Church. The Seizures form should be used for any person participating in events that have any medical conditions such as seizures. The form is valid for one year. If something isn't applicable please use N/A.

A copy of this release may be used as if it were an original.

Participants Information

First Name

Last Name

Do you attend Fairhaven Church weekend services?

If yes, which campus do you attend?

Cell Phone

Date Of Birth

Gender

Address

Emergency Contact

Emergency Contact Name

Emergency Contact Number

Emergency Contact Relationship

Allergies & Medication

Please list any allergies, medical conditions, or medications we should be aware of in case of an emergency.

Allergies and Medication