New Images Ministries
See Yourself in New Images
Hunting & Fishing
Our Ministry
New Images Ministries
See Yourself in New Images
Hunting & Fishing
Our Ministry
Health History & Release Form
First, Middle, Last Name
*
First Name
Last Name
SSN
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Age
Date of Birth
Phone
(###)
###
####
Do you have any allergies?
Yes
No
Select 1
Do you have any history of anaphylactic shock? (allergic reaction to bee stings)
Yes
No
Are you allergic to, or have adverse reactions to, and medications?
Yes
No
Are you currently on any medications or treatments?
Please provide type and dosage below
Yes
No
Has your physical activity been restricted in the past year?
Yes
No
Have you had any illness or injury, or been hospitalized, in the past year?
Yes
No
Do you have any condition NIM should be aware of that might jeapordize your safety or that of anyone else on the trip?
Yes
No
Please comment on any "Yes" answers from above here:
Emergency Contact
Emergency Contact Name
First Name
Last Name
Emergency Contact Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact Phone
(###)
###
####
Emergency Contact Relationship
Insurance Information
Insurance Company
Policy Number
Checkbox
Option One
Option Two
Participant Signature
Please be prepared to sign printed form
Parental Signature (for participants under 18)
Please be prepared to sign printed copy
Thank you!