Emergency Medical Form

Women’s Renewal Weekend Emergency Medical Form

This completed form must be brought to registration by each person attending. Please PRINT information clearly with blue or black ink. Please also be sure to bring your medical health insurance card.

* Food and Allergy Restrictions- Please send in Form immediately so that we may better accommodate you.

Name:____________________________________________ DOB___/___/___ Age ____

Last First M.I. M D Y

Address:__________________________________________________________________

Number and Street City/State/Zip

Phone: (_____)_________________ Cell: (_____)________________

If you are under 18 and here with an adult relative please list her Name:__________________________________ Relationship:____________________

Name two relatives/friends who may be contacted in case of an emergency:

1. Name: ___________________________________ Relationship:________________

Address: ____________________________________________________________

Phone: (_____)__________________ Cell: (_____)_________________

2. Name: ___________________________________ Relationship:________________

Address: ____________________________________________________________

Phone: (_____)__________________ Cell: (_____)_________________

PHYSICIAN: Doctor’s name:______________________________________________

Address:_______________________________________________________________

Phone: (_____)_____________________

*ALLERGIES: Do you have any allergies to food?_____ If yes, list which food(s):

________________________ ___________________ ____________________

Others:_________________________________________________________________

*FOOD RESTRICTIONS: Do you have any Food Restrictions?_______ If yes, what are they?______

_______________________________________________________________________________

Do you have any known allergies to drugs/medicine?_____ If yes, list which drug(s):

_________________________ __________________ ____________________

MEDICATION: Are you bringing medication with you? _____ If yes, give name(s):

________________________need refrigerated? ____ __________________________ ____

(Note: Directions for administering, name of medication, and patient’s name must be on the label.)

In the event of an emergency, I certify I am over the age of 18 and hereby give permission for the physician selected by the officials of this organization to provide whatever medical or surgical treatment is necessary.

Signed__________________________________________________ Date________________

Print name_________________________________________________________

(If signing for a minor, please check one: Parent_____ Legal Guardian______)