PARTICIPANT: _____________________________________________________

Phone: (home) ___-___-____     (cell) ___-___-____

Emergency Contact:   _____________________________________________

Phone: (home) ___-___-____     (cell) ___-___-____

Primary Care Physician: _________________________   Phone: ___-___-____

Allergies: ________________________________________________________

Medical Conditions: _______________________________________________

Prescription Medications: (name : dosage : when taken)

_____________________ : ________ : ________________

_____________________ : ________ : ________________

_____________________ : ________ : ________________

Medical Alert Device - bracelet, etc. (yes/no): ____

Activities To Be Careful Doing: _______________________________________

First Aid Training (yes/no): ____

Emergency Medical Technician Training (yes/no): ____

ADDITIONAL INFORMATION:

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