Participant’s Personal Information (Minor)

The following is requested in case of emergency

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's                                                                                                                

Signature: _______________________________________________________________Date: ___/___/___   

Additional Comments: