Release and Waiver

Each year EMS Road Docs of Illinois members are required to complete and submit a Release and Waiver form.

By completing and submitting the below form a PDF document will be dynamically created with the blanks already completed with the form data provided. This form will then be e-mailed to you at the e-mail address provided. Please ensure accuracy of the data provided before submitting the form. Once you receive the document please sign it and deliver to the address provided in the e-mail you receive.






First Name
(required)
Last Name
(required)


E-Mail Address
(required)
Phone Number
(required)


Street Address
(required)

City
(required)
State
(required)
Zip Code
(required)