Medical Information Form

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Participant Information

Participant's Name (required)

Parent's Email (required)

Participant's Date of Birth (required)

Gender:  Male Female

Participant Health Information

Health Card #:

Doctor's Name:
Doctor's Phone:
Doctor's Pager:

Will the participant be carrying or requiring any medication to be taken/administered at lessons/camp?
 Yes No
Please Specify:

Does this participant have any health or behavioral conditions we should know about (allergy information to be listed below)?

Participant's Allergies

You are required to fill out this section if your child has a known or suspected allergy and is at risk for allergic complications and/or anaphylaxis.

This child has a dangerous Life-threatening allergy to the following substances:

This child will react to the above listed substances upon:
 Inhalation Contact Ingestion

Please list any detailed information about your child's allergy:

Symptoms (known) specific to your child (0 – 15 minutes after consumption or contact):

Any other medication to be given, with specific instructions:

Parental Consent for EPI-PEN use

Does the Participant require an EPI-PEN?  Yes No
EPI-PEN Location:
2nd EPI-PEN carried?  Yes No

In the event of an emergency, I give permission for a Staff Member trained in Emergency procedures and First Aid to assist my child ­in administering their personal EpiPen.
 Yes No