Iowa TDC Medical Release

**If you are registering multiple attendees, you must fill out one form per individual**

Fields marked with an * are required.

Please verify that you have checked the “I'm not a robot” checkbox.

Contact Information

Medical Authorization
In case of emergency, if family physician cannot be reached, I am hereby authorized to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, E.R. Physician).

If Other, please write in the name of the hospital below

Please list any allergies/medical problems, including those requiring maintenance medication (i.e. Diabetic, Asthma, Seizure Disorder, Cardiac, etc.)

Emergency Contact

Company Rep On-Site

Company Rep On-Site

Company Rep On-Site

Please list your hotel name or location of accommodations