Professional Documents
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Missouri Personal Liability and Medical Release Form
Missouri Personal Liability and Medical Release Form
MoTSA
FORM
Read the other side of this form. Then, complete the entire form. Type or print clearly. You must wear your name badge to gain entry
to conference functions.
Local TSA Chapter:
Parents Names:
City:
State:
ZIP Code:
Check one:
Event
Complete this
section.
All complete
this section.
City:
State:
ZIP Code:
Age:
?
?
?
?
Check one:
? Male
? Female
Contest
Abbreviation:
Contest Name:
? Contestant
? Advisor (Teacher)
? District Officer
? State Officer
? Participant
? Observer / Other
________________
Family Physician:
State:
ZIP Code:
Guarantors Relationship to
Participant:
Photocopy
Guarantors Employer:
your insurance
card and
attach the
Employers Address:
copy to the
back of this
form
City:
? No
? Yes
? No
? Yes
? No
? No
? Yes
)
State:
ZIP Code:
Insurance Company:
If you dont
have
Insurance,
sign where
noted
City:
State:
ZIP Code:
Signature of participant
Date
PARTICIPANTS______________________________________________________________
CHECK HERE IF YOU ARE OVER 18 AND CAN SIGN FOR YOURSELF: ?
Signature of Participant
Date
Having read and understood completely the Personal Liability and
Medical Release, the Code of Conduct, and the Photography and
Sign the
______________________________________________________________
Sound Release agreements on the other side of this form, I, by
Signature of Parent or Guardian (mandatory if under age 18)
Date
agreement signing at right, do hereby agree to abide by these in their entirety
and completely release Missouri TSA, Inc.
THIS COMPLETED
FORM
MUST BE&
TURNED
OR PARTICIPANT
NOT BE ALLOWED TO ATTEND.
Rev. 11/26/01
http://www.ProWaiver.com
Free
Templates
Forms IN,
Download
for Free atWILL
http://www.prowaiver.com/power-of-attorney-form.php