Name: __________________________
Address: ______________________________
_____________________________
_____________________________
Date of Birth: _____/_____/______ Age: ______ Sex: Male / Female
If under the age of 18:
Name of participant/guardian: ______________________________
Home telephone: ___________________________
Mobile / Work telephone: ______________________________
Emergency contact (if the person above is not available to support emergency purposes)
Name: ___________________ Relationship: _____________________ Contact: _________________
Medication:
Do you take any medication? Yes / No
If yes, please state the specific medication and reason for taking it: ______________________________
How often do you take this medication? (Remember to include dosage amount)
______________________________
Do you have any allergies? Yes / No
If yes, what specific allergies do you have
______________________________
Is there anything else regarding medical issues that you think we should know about?
______________________________
(If you are over 18)- I agree to look after my medication myself and take my medication when I need to or if an emergency situation occurs, allow one of the team members to give me my medication
Signed: ______________________ Date: _____ / ______ / _______
(If you are under 18)- I agree for my son/daughter to take care of their medication themselves and take it when they need to, also I allow any team member to give them their medication in case of an emergency
Parent / Guardian signature: __________________________ Date: ____ / ____ / ____
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