Appendix C

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: _______________________________________________________

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.