Appendix C

 

Link to: Appendix C: participant_medical_form.doc (Voluntary) 

(You will first be asked if you wish to Open or Save the file. Your choice. Then you will be asked to sign in to the www.lively-dragon.com website. Click cancel and the document will open. Then select enable editing to edit the document.

(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: _______________________________________________________

Medications: _________________________________________________________________________

Blood Type: _________________________________________________________________________

Allergies: ____________________________________________________________________________

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.