Medical Information and Emergency Contacts

Emergency Contact and Medical Information – CrazYman Training Challenge - October 2016
									M	F
Name				Date of Birth					Sex
Cell Phone		Home Phone		Work Phone				Other
Address				Address
City, ST,  ZIP Code				City, ST,  ZIP Code
Alternative Emergency Contacts
Primary Emergency Contact				Secondary Emergency Contact
Home Phone		Work Phone		Home Phone				Work Phone
Address				Address
City, ST  ZIP Code				City, ST  ZIP Code
Medical Information
Hospital/Clinic Preference
Physician’s Name						Phone Number
Insurance Company						Policy Number
Special Health Considerations;
Allergies
I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for me and waive my right to informed consent of treatment if incapacitated. This waiver applies if an authorized contact cannot be reached in the case of an emergency.
Signature						Date
I release Slade Coaching and individuals Linda Slade and Henry “Skip” Slade from liability in case of accident or health issues that occur during this training event related to Slade Coaching and CrazYman Training Challenge, as long as normal safety procedures have been taken.
Signature						Date
Witness Signature						Date

NOTE: This form will be shredded when it is no longer needed. It will ONLY be used in connection with this training event.