Worker's Medical Form

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
Should be Empty: