HERITAGE HIGHLANDS HIKING CLUB Print This Form
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NAME: |
BIRTHDAY: |
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STREET ADDRESS: |
PHONE: |
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INSURANCE CO: |
POLICY NO: |
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PHYSICIAN: |
DR's. PHONE: |
Please place your initials in the space provided for all conditions which apply.
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HEART CONDITION |
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ASTHMA |
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BREATHING PROBLEMS |
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DIABETIC |
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SEIZURES |
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HIGH BLOOD PRESSURE |
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EMOTIONAL PROBLEMS |
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HARD OF HEARING |
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ALLERGY TO BEES, WASPS, ETC |
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ALLERGIES TO OTHER INSECTS (PLEASE LIST):
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ALLERGIES TO ANY MEDICATIONS (PLEASE LIST):
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OTHER MEDICAL CONCERNS:
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For all items initialed above, please indicate any specific treatment or medications to be (or not to be) administered in case of emergency: ____________________________________________
IN CASE OF EMERGENCY, PLEASE NOTIFY:
NAME: ___________________________________________________________________
RELATION: _______________________ PHONE NUMBER: _________________________
I HEREBY AUTHORIZE _______ DO NOT AUTHORIZE ________ ANY BASIC FIRST AIDE PROCEDURES TO BE TAKEN IF IT IS DEEMED NECESSARY.
SIGNATURE: ________________________________________ DATE: _________________ | 
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