2023 SPEEDWEEK Medical Form

Southern California Timing Association
Medical Form

Form Must Be Filled Out Completely
Vehicle No.*
Name*
Age*
Address*
City*
State*
Zip*
Support Crew at Event
Name*
Phone*
Name
Phone
Name
Phone
Emergency Contact
Name*
Relation*
Phone*
2nd Phone
Alternate Contact Name*
Phone*
Primary Medical Insurance

If questions do not apply to you please put "N/A"
Do You Have Medical Insurance*

YesNo
Insurance Carrier*
I.D. Number*
Group*
Subscriber*
Medical Information
Physician*
Phone*
Date of Last Tetanus Shot*

MonthDayYear
Date
Date of Last Exam*

MonthDayYear
Date
Prescription Medications (Please List)*
Type 'None' if you do not have any Prescription Medications
Prescription Medications (Please List)
Allergies to Medications*
Type 'None' if you do not have any Allergies
Past Surgical History*
Other Medical Issues*
Check All That Apply Below or Write 'none' Above
Other Medical Issues That Apply

Insulin Dependent DiabeticHeart DiseaseHigh Blood PressureRespiratory ProblemsPrevious Head InjuriesBlood Problems - AnemiaBlood Problems - Clotting DifficultiesMusculoskeletal ProblemsMalignancySeizure Disorder
Other Special Needs *
Other Special Needs
Please Answer All Questions Below
Contact Lens*

YesNo
Dentures*

YesNo
Asthmatic*

YesNo
Diabetic*

YesNo
Pace Maker*

YesNo
Epileptic*

YesNo
Hemophiliac*

YesNo
Hearing Impaired*

YesNo
Hypertension*

YesNo
Pregnant*

YesNo
Allergies*

YesNo
Authorization for Emergency Care: In case or 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 of surgery is agreed upon by two (2) physicians’ judgment.
Signature (Sign By Using Your Mouse - Hold Left Button Down and Draw your Signature)*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Southern California Timing Association

Medical Form

Support Crew at Event

Emergency Contact

Primary Medical Insurance

Medical Information

Please Answer All Questions Below