Participant’s Personal Information (Adult)

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 (not with you) 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: _______________________________________

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 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 :________________________________________

________________________________________________________________________________________

_______________________________________________________________________________________

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

_________________________________________________________________________________________

_________________________________________________________________________________________

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Participants                                                                                                                         Today’s

Signature: _______________________________________________________________Date: ___/___/___   

Additional Comments: