The New Mexico Roadrunners J.O.A.D. Archery Club
Medical Release and Information
This form is for informational purposes only. The information contained is for use only incase of emergency while in the facilities used by the New Mexico Roadrunners JOAD Archery Club. We will not share or use the information for any other reason but medical necessity. All information disclosed is confidential.
Personal information:
Name__________________________________________________________-
Date of birth___________________________
Age________________
Male/ female
Street address____________________________________________
City, state, zip____________________________________________________
Home number__________________________________
Cell number__________________________________
Person to contact incase of emergency:
Name__________________________________________________
Relationship to archer____________________________________
Home Phone number______________________
Cell phone number____________________________
Physician to contact:
Name_____________________________________________
Phone _____________________________________________
Can we call Emergency (911) if needed? _______________________
Are there any medical conditions that we should know about that we would need to know? Please tell us_______________________________________________
In case of emergency, I understand every effort will be made to contact me( if minor is archer) I hereby
give permission to the licensed health care professional selected by the adult leader in charge to secure proper treatment for my child or myself( if an adult).
Signature of parent or guardian___________________________________
Date____________________________________