Name: _____________________________________________________________

  

Date of Birth: ________________________________________________________

 

Address: ___________________________________________________________

 

City, State, Zip: ______________________________________________________

 

Home Phone: ________________________________________________________  

 

Work Phone: ________________________________________________________

 

Mobile Phone: _______________________________________________________   

 

Email: ______________________________________________________________

 

Social Security Number: ________________________________________________

 

Family Doctor: _______________________________________________________  

 

Doctor's Phone #: _____________________________________________________

 

Name of Person to Contact in an Emergency: ____________________________________________________________________________________________________________

 

Contact's Home Phone: _________________________________________________    

 

Contact's Work Phone: _________________________________________________

 

Contact's Mobile Phone: ________________________________________________  

Medical History

 

General Health Concerns: _____________________________________________________________________

 

Emergency Health Conditions (severe insect allergy, heart condition, seizures, convulsions, bleeding problems, diabetes, etc.): _____________________________________________________________________

 

Major Illness or Injury (injuries, operations, hospitalizations) including where and when:

_____________________________________________________________________

 

Any Current Medications (prescription or over the counter): ________________________

 

Any Allergies: ___________________________________________________________

 

Please Give Details & Medications:___________________________________________ ______________________________________________________________________

 

Any Restrictions on Physical Activity: ______ If so, What: __________________________

______________________________________________________________________ 

 

Date of Last Tetanus Shot: __________________________________________________

 

In case of an emergency, when neither parent nor next of kin can be reached by telephone,

I, _____________________________, give my permission to David Hearn, Jennifer Hearn, or Ben Kvanli to arrange for an operation or other treatment, and to sign permission on my behalf for the administration of a general anesthesia by a qualified anesthetist.

 

Signature: _______________________________________________

 

Date: ________________________