Iowa TDC Medical Release

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

Contact Information

First Name *

Last Name *

Organization *

Phone

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).

Medical Diagnosis/Medication/Dosage/Frequency of Dosage

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

Emergency Contact

First Name *

Last Name *

Phone *

Relationship

First Name

Company Rep On-Site

Last Name

Company Rep On-Site

Phone

Company Rep On-Site

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