Iowa TDC Medical Release - Iowa Motor Truck Association

Iowa TDC Medical Release

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

Fields marked with an * are required.

Contact Information

First Name *

Last Name *

Address Line 1 *

Address Line 2

City *

State *

Postal Code *

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).

Family Physician *

Phone

City

State

Hospital Preference *

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

Other Hospital Name

Insurance Co.

Policy No.

Group ID#

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

Event Accommodations

Please list your hotel name or location of accommodations

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