Participant's Personal Information (Minor)
The following is requested in case of emergency
This information will only shared with medical personnel if/when needed.

Remember...if you are unconscious; your life may depend on your answers!

Participants Name

(please print clearly) _____________________________________________________________Age:______

Person to contact in case of emergency: ___________________________________________________

Relationship: ___________________________  Phone: ________________________________________

Vehicle; Make/Model: _________________________ Plate #: _______________________ State: _____

Your Blood Type: _________  Medical Allergies: ______________________________________________

Are you taking any medication? ____ Detail:__________________________________________________

Is there medication that you need with you? ____ Detail: _______________________________________

_______________________________________________________________________________________

 Is this medication with you? ____ Where do you keep it? ________________________________________

 Are you wearing contact lenses?   No / Yes   Dentures or Dental Bridges?       No / Yes 

 Medical/Physical Conditions that we should be aware of :________________________________________

________________________________________________________________________________________

_______________________________________________________________________________________

________________________________________________________________________________________

Special Conditions / Instructions (pets/baby sitters) that we should be aware of: ______________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Participant's Signature__________________________________________________Date: ____/____/_____   

I have reviewed the above information and confirm the accuracy, and consent to my child's participation:
 

Parent / Guardian's Signature: _____________________________________________Date: ___/___/_____

Parent / Guardian's Printed Full Name _______________________________________________________

Additional Comments:

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Link to: Minor Waiver & Consent Form