Language
English (US)
Workers Assignment
*
Your Name
*
T-Shirt Size
*
(S, M, L, XL, 2X, 3X OR 4X
Birthdate
*
/
Month
/
Day
Year
Date
Address
*
City
*
State
*
Zip
*
Your Cell Phone #
*
Do you have Medical Insurance
*
Type option Yes
No
Insurance Carrier Name
Carrier ID No
Subscriber
Group
Physician Name
Physician Phone
Tetanus Shot Date
/
Month
/
Day
Year
Date
Last Exam
/
Month
/
Day
Year
Date
Prescriptions
*
Type "None" if this does not apply
Allergies
*
Type "None" if this does not apply
Past Surgeries
Type "None" if this does not apply
Check All That Apply
Insulin Dependent Diabetic
Heart Disease
High Blood Pressure
Previous Head Injuries
Respiratory Problems
Blood problems - Anemia
Blood problems - Clotting
Musculoskeletal Problems
Malignancy
Seizure Disorder
Other Special Needs
Special Needs #1
Special Needs #2
Special Needs #3
Special Needs #4
Emergency Contact On Salt
Name
*
Relation
*
Phone1
*
Phone2
Other Emergency Contact
Name
*
Phone
*
If you are also Racing or on a Crew - Please Fill Out the Information Below
Entry #
Support Crew Name #1
Cell Phone1
Support Crew Name #2
Cell Phone2
Authorization for Emergency Care: In case of an emergency, wherein I am incapable of giving consent due to illness or injury, I authorize any qualified person to administer first aid and/or other necessary treatment. I further authorize any licensed surgeon to perform life-saving surgery, if the need for surgery is agreed upon by two (2) physician's judgment.
Signature - Draw With Your Mouse
Clear
Signed Date
/
Month
/
Day
Year
Date
Preview PDF
Submit
Should be Empty: