Event Medical Information Form

BIB/EVENT #
If you are on a relay team enter your bib number or your team name. You can use the participant list found on the event website to find your bib number
Event Medical Information Form
Instructions: Please complete this form. You will not receive your event packet until this form is filled out and submitted.
Participant Name:

First NameLast Name
Age:
Event Day Emergency Contact Info: Name:

First NameLast Name
Emergency Contact Phone:
Format: (000) 000-0000.
Recent travel outside of the U.S? If yes, when and where.
Type NONE if no recent travel outside the US
CHECK ALL ITEMS THAT APPLY TO YOU

Other
Recent surgery/hospitalization:
Type NONE if no surgeries or hospitalizations
Allergies (Medicines, Foods etc):
Type NONE if no allergies
MEDICATIONS
List any medications (and dosages) you are currently taking:
Type NONE here if you aren't taking any medications
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Should be Empty: