Medical Information UPDATE 2023 – Driftwood Martial Arts

PARTICIPANT INFORMATION

Program / Class *

Participant Name *

First

Last

Participant Birthdate *

Personal Pronouns (ie: she/her, he/him, they/them)

EMERGENCY CONTACT INFORMATION

Emergency Contact *

First

Last

Phone *

Relationship to Participant *

PARTICIPANT MEDICAL INFORMATION

Please complete all responses. Provide extra information at the bottom of the form.

Are vaccinations up-to-date? (Does not include Covid) *

is the participant currently injured? *

Provide injury details:

Does the participant have any ALLERGIES? *

Provide allergy details:

Does the participant have any BREATHING ISSUES? *

Provide details about breathing issues:

Has the participant been diagnosed with HIGH/LOW BLOOD PRESSURE? *

Has the participant been diagnosed with a HEART CONDITION? *

Provide heart condition details:

Is the participant DIABETIC? *

Does the participant have a history of NOSEBLEEDS? *

Is there a history of CONCUSSION(S)? *

When was the last concussion?

Does the participant experience CHRONIC PAIN? *

Chronic pain information:

Does the participant wear a MEDIC ALERT? *

Has the participant had SURGERY in the past 12 months? *

Provide surgery details:

Does the participant have any concerns with ADD/ADHD/ASD or similar? *

Provide details:

MEDICATION Information:

Additional Information

Please provide any important information not covered above.

DECLARATION

Declaration *

I declare that I have correctly completed this form to the best of my knowledge. I am aware that Driftwood Martial Arts Inc. will not be responsible for injuries due to non-disclosure of information. I understand that it is my responsibility to keep Driftwood Martial Arts Inc. advised of any changes to the information provided.

Name of person completing form: *

First

Last

Date of Completion *

STUDENT MEDICAL INFORMATION

PARTICIPANT INFORMATION

EMERGENCY CONTACT INFORMATION

PARTICIPANT MEDICAL INFORMATION

DECLARATION

Our Mission

Driftwood Martial Arts

Administrative Hours