STUDENT MEDICAL INFORMATION

THIS FORM MUST BE COMPLETED IN FULL BEORE PARTICIPATING IN ANY PROGRAMS, CLASSES OR CAMPS.
All information is kept confidential and will only be disclosed in the event of a medical emergency or if first aid treatment is required.

PARTICIPANT INFORMATION

Driftwood Program *

Participant Name *

First

Last

Birthdate *

EMERGENCY CONTACT INFORMATION

EMERGENCY Contact *

First

Last

Phone *

Relationship

PARTICIPANT MEDICAL INFORMATION

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

Are vaccinations up-to-date?

Is the participant currently injured?

Does the participant have any ALLERGIES? (ie: food, drug or environmental) - If YES please describe.

Does the participant have any BREATHING ISSUES? (ie: Asthma, COPD)

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

Has the participant been diagnosed with a HEART CONDITION?

Is the participant DIABETIC?

Does the participant have a history of NOSEBLEEDS?

Is there a history of CONCUSSIONS

If YES to CONCUSSION, date of last concussion?

Does the participant experience CHRONIC PAIN? (ie: Back / Neck / Joint)

Does the participant wear a MEDIC ALERT?

Has the participant had SURGERY in the last 12 months?

Provide details to any above answers that require more information.

MEDICATIONS

Please list any medications the participant is currently taking including over-the-counter and prescription.

ADDITIONAL INFORMATION

Please include any information not covered above.

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

Phone

STUDENT MEDICAL INFORMATION

PARTICIPANT INFORMATION

EMERGENCY CONTACT INFORMATION

PARTICIPANT MEDICAL INFORMATION

DECLARATION

Our Mission

Driftwood Martial Arts

Administrative Hours