MEDICAL INFORMATION
NAME OF PARTICIPANT___________________________ Date of Birth ___________
Address _________________________________ Male __________ Female __________
City ____________________________ Zip _________ Phone ____________________
IN CASE OF EMERGENCY, PLEASE NOTIFY:________________________________
Phone: Day ______________ Evening_____________ Cell/Beeper ______________
Relationship to Participant: _________________________________________________
Emergency Information (Family Physician or Clinic):
Name_______________________________ Emergency Phone ____________________
Address_______________________ City _________________ State _____ Zip _______
Insurance Company: ______________________________________________________
Policy Carrier: _______________________ Policy Number: _______________________
**YOU MUST ENCLOSE A PHOTOCOPY OF THE PARTICIPANT’S MEDICAL CARD**
HISTORY:
Are there any limitations to the activities in which your child can participate?
Yes ____ No ____ If yes, please explain ________________________
Is there anything about your child's health that we should be aware of such as:
_____Diabetes _____Fainting Trouble _____Epilepsy
_____Heart Problems _____Migraines _____Bleeding Disorders
_____Asthma _____Severe Allergic Reactions (Bee Sting / Food / Other)
_____Any other health issues we should be made aware of: _________________________
If any of the above is checked, please submit a statement of how the person has been treated and with
what medications: __________________________________________________
________________________________________________________________________
My child is or may be allergic to: _____________________________________________
My child must take the following medications: ___________________________________
Please indicate dosage, frequency, reason for medication, etc._________________________
________________________________________________________________________
*PLEASE BE ADVISED THAT ADULTS CAN NOT DISPENSE ANY MEDICATIONS*
Please give the dates of the last shots for the following
Tetanus_______________ DPT________________ PPD (TB)______________
Signature of Parent or Guardian: ________________________ Date: ________