2026 ACC Minors Medical Release Waiver

Work Entry

Added: 1/8/2026

Minor First Name

Minor Last Name

Minor Date of Birth

Minor Gender

Minor Address

Minor Tetanus Immunization Status

Minor Date of last Tetanus Shot

Minor Medications

Minor Allergies

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

Physician Name

Physician Phone Number

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