2022 Driver Medical Form

Slinger Speedway

2022 Medical/Emergency Information
On behalf of the Slinger Safety Team we would like to thank you for taking the time to fill out this form. If you do not know any of the requested information leave it blank. All information provided on this form will only be used in case of emergency and viewed by only the necessary staff that is involved in your care.
Driver Name *
CAR NUMBER *
Division(s) *
D.O.B *
Primary Doctor
Phone #
Emergency Contacts (Please list at least one even if they are at the track with you):
Name and Relationship *
Phone # *
Name and Relationship
Phone #
Please List All Allergies
Please List All Medication Names
Medical History (Please check all that apply)

Asthma Anxiety or Depression Cancer (if currently being treated please let us know) Cardiac-Arrhythmia/A-Fib Cardiac-Defibrillator Cardiac-Pacemaker Congestive Heart Failure COPD/Emphysema Diabetes GI Problems Heart Attack High Blood Pressure Kidney Failure Liver Disease Low Blood Pressure Stomach Ulcer Seizures Stroke/TIA/CVA Thyroid Disorder Other
Do you wear glasses or contacts?

Yes, Glasses Yes, Contacts No
Please let us know if you have had any surgery in the past year.
Have you had a concussion or loss of consciousness in the past year? If so when?
Should be Empty:

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Slinger Speedway