2025 ACC Minors Medical Release Waiver

Work Entry

Minor's Information

Minor 1 First Name

Minor 1 Last Name

Minor 1 Date of Birth

Minor 1 Gender

Minor 1 Address

Minor 1 Date of last Tetanus Shot

Minor 1 Medications

Minor 1 Allergies

Minor 2 Information

Minor 2 First Name

Minor 2 Last Name

Minor 2 Date of Birth

Minor 2 Gender

Minor 2 Address

Minor 2 Date of last Tetanus Shot

Minor 2 Medications

Minor 2 Allergies

Minor 3 Information

Minor 3 First Name

Minor 3 Last Name

Minor 3 Date of Birth

Minor 3 Gender

Minor 3 Address

Minor 3 Date of last Tetanus Shot

Minor 3 Medications

Minor 3 Allergies

Minor 4 Information

Minor 4 First Name

Minor 4 Last Name

Minor 4 Date of Birth

Minor 4 Gender

Minor 4 Address

Minor 4 Date of last Tetanus Shot

Minor 4 Medications

Minor 4 Allergies

Parent/Guardian/Emergency Contact Information

Emergency Contact's Name

Emergency Contact's Phone Number

Insurance Carrier

Insurance Policy Number

Parent/Guardian's Driver's License / ID Card Number

Parent/Guardian's Driver's License / ID Card Issuing State

Parent/Guardian's Email Address

Parent/Guardian's First Name

Parent/Guardian's Middle Name

Parent/Guardian's Last Name

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