Team Medical Form
Team Member Name
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First Name
Last Name
Do you have any medical conditions that we should be aware of?
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Do you have any food or other allergies that we should be aware of?
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Do you have any mental health issues that we should be aware of?
*
Will you be bringing prescribed medication from home?
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Yes
No
What medication(s) do you take?
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Please list each on a new line. If not applicable, please write N/A.
What is the dosage of the medication(s)/tablet(s)?
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Please list each on a new line, so that it matches previous answers. If not applicable, please write N/A.
How many tablets do you take at a time?
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Please list each on a new line, so that it matches previous answers. If not applicable, please write N/A.
At what time(s) do you take the medication?
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Please list each on a new line, so that it matches previous answers. If not applicable, please write N/A.
Date
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Month
/
Day
Year
Date
Team Emergency Contact
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
-
Area Code
Phone Number
Emergency Contact Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please describe team member's relationship to Emergency Contact.
*
Please read the alternative statements below and select the one you choose.
*
If I need medical attention, it is my wish that the Emergency Contact is contacted before any medical procedures is taken, unless immediate treatment is necessary to save my life or to prevent permanent injury. I accept responsibility for all costs related to such treatment.
If need medical treatment, it is my wish that the treatment is started while efforts are being made to contact the Emergency Contact. So that treatment is not delayed, I consent to any medical procedures, on the understanding that efforts to contact the Emergency Contact will continue to be made. I accept responsibility for all costs related to such treatment.
Team Member Signature
*
Date
*
/
Month
/
Day
Year
Date
Submit
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