The Environmental Forum of Marin P. O. Box 150459 San Rafael, CA 94915-0459 Telephone: 415-479-7814 www.marinefm.org You may print this page and fill it out by hand, or enter the information below and then print and sign it. Any information you submit will be held CONFIDENTIAL by the Environmental Forum of Marin. MEDICAL RELEASE I hereby authorize the staff of the Environmental Forum of Marin to act for me according to their best judgment in any emergency requiring medical attention during Training Programs. I also hereby waive and release the Environmental Forum of Marin from any and all liability for any injuries or illnesses incurred while participating in Training Programs. I have no knowledge of any physical impairment which would be adversely affected by my participation in the Training Programs. Trainee Name:   Signature:_______________________________________   Date:________________________ Person to be notified in case of emergency. Name: Address: City/St/Zip: Telephone: Relationship to Trainee: Physician's Name: Physician's Telephone: If you will be using your vehicle during the Training Program, our insurance carrier requires that we have the following information: Make/year of vehicle: Registered to: Your Driver's License no.: License expiration date: Insured by: Policy Number: