Link to: Appendix C: participant_medical_form.doc (Voluntary)
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(Team captain please insure this form is readily available to team members)
Participant Medical Information Form "" this is at the paddlers discretion""
Name: ________________________________________ Sex ( ) M ( ) F
Date of Birth: Day ______Month _______________Year ____________
Person to be contacted in case of emergency _______________________________________________
Phone numbers: Day __________________ Evening_______________________
Family Doctor: __________________________ Phone number: ______________________
Relevant Medical History:
Important Medical Considerations: _______________________________________________________
Blood Type: _________________________________________________________________________
Previous injuries illnesses or operations:
Can the participant/athlete administer his/her own medication(s) Yes (_______) No (________)
Medication instructions: _________________________________________________________________
(Please note we are not authorized to give medication but can assist you with your medication)
Other concerns: (Prosthesis, contact lenses, etc.) notes:
I assume full responsibility for my health being such that the activities will in no way aggravate any conditions present or present a risk to my fellow paddlers. If in doubt, I will seek and follow medical advice.
Signature: ___________________________________ Date: ___________________________
Note: participant / athlete Participant Medical Information Form is confidential.
We will turn it over to medical assistance if a medical emergency arises.