Emergency Contact and Medical Information
– CrazYman Training Challenge – 2017
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Name
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Date of Birth
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Sex
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Cell Phone
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Home Phone
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Work Phone
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Other
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Address
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Address
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City, ST, ZIP Code
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City, ST, ZIP Code
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Alternative Emergency Contacts
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Primary Emergency Contact
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Secondary Emergency Contact
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Home Phone
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Work Phone
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Home Phone
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Work Phone
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Address
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Address
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City, ST, ZIP Code
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City, ST, ZIP Code
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Medical Information
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Hospital/Clinic Preference
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Physician’s Name
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Phone Number
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Insurance Company
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Policy Number
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Special Health Considerations;
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Allergies
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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.
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Signature
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Date
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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 followed.
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Signature
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Date
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Witness Signature
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Date
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NOTE: This form will be shredded when it is no longer
needed. It will ONLY be used in connection with CrazYman training events. If
you prefer to take possession after the event, just ask.