Medical Form

Medical Form:

Name: ……………………………………………………………………….

Address: …………………………………………………………………………………………………………………………………………........................................................................................................................................................................................................................................................................................................................................................

Date of Birth: ……………………………………..                                    Age: ……………….                                    Sex: M/F

If under 18:

Name of participant/guardian: ……………………………………………………………………………………………………………

Home telephone: …………………………………………                  Mobile/work telephone: …………………………………………

Emergency Contact: (if person above is not available in case of an emergency)

Name: …………………………………….. Relationship: …………………………………. Contact: …………………………………

Medication:

Do you take any medication?                   Yes/No

If yes, please state the medication you take and why you take it …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

How often do you take this medication and at what dosage ……………………………………………………………………………………………………………………………………………………………

Do you have any allergies?                  Yes/No

If yes, what allergies do you have …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Any other medical issues you think we may need to know? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

(If over 18) – I agree to look after my medication myself and take my medication when I need it or if in an emergency allow one of the team members to give me my medicine

Signed ……………………………………………………………………..                  Date …………………………………..

(If under 18) – I agree for my son/daughter to take care of their medication themselves and take it when they need it and I also allow any team member to give them their medication in case of an emergency

Parent/Guardian signature ……………………………………………………………