Medical Authorization Form

Participant Information

Name(Required)

First Last

Birthdate(Required)

Please list all allergies or pertinent medical conditions Back2Back Cincinnati should be aware of regarding the participant(Required)

Emergency Contact Information

Guardian's First and Last Name(Required)

First Last

Guardian's Phone Number(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact's First and Last Name(Required)

First Last

Emergency Contact's Phone Number(Required)

Custody(Required)

Please list information regarding custody arrangements/restraining orders (persons who may not visit or take your child under any circumstances) or indicate if this does not apply. Please be aware Back2Back Cincinnati cannot withhold a child from a parent/guardian without appropriate court documents stating such on file

In Case Of Emergency:(Required)

If the guardian and emergency contact listed above are not available in an emergency, I give permission for Back2Back Cincinnati staff to plan for the care of me/my student(s) and/or transport me/my student(s) to the hospital.

Yes

No

Guardian Signature (if participant is under 18)(Required)

First Last

Date(Required)

Participant’s Signature (if over 18)

First Last

Date

Participant Information

Emergency Contact Information

Release of Information

Release of Information (ROI) Consent

Medical Authorization Form

Participant Information

Emergency Contact Information

Sponsor A Child or Family

Release of Information

Release of Information (ROI) Consent

Take A Mission Trip

Job Inquiry Form

Write A letter

Back2Back Intern Application