Identification:
Parent Name: _____________________________________ Date of Birth:__________ Age____ Sex____
Parent Name: _____________________________________ Date of Birth:__________ Age____ Sex____
Guardian Name: _________________________________ Date of Birth:__________ Age____ Sex____
Child’s Name: ____________________________________ Date of Birth:__________ Age____ Sex____
Child’s Name: ____________________________________ Date of Birth:__________ Age____ Sex____
Child’s Name: ____________________________________ Date of Birth:__________ Age____ Sex____
Child’s Name: ____________________________________ Date of Birth:__________ Age____ Sex____
Child’s Name: ____________________________________ Date of Birth:__________ Age____ Sex____
Child’s Name: ____________________________________ Date of Birth:__________ Age____ Sex____
Home Address:_______________________________________________City:________________ NC Zip:_______
Telephone: ___________________________ Cell Phone: ____________________________________________________
Name of Personal physician: _______________________________________________Telephone:_____________________
Personal health/accident insurance carrier:__________________________________________________________________
Policy Number:____________________________________________
Please list any Allergies for the above named participants:
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Please list any MEDICINES that CAN NOT be given to the above named participants:
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Please list any additional conditions or information we should know of in case of an emergency:
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Please list an emergency contact person and telephone number:
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Authorization:
This health history is correct so far as I know, and the person(s) herein described has permission to engage in all prescribed activities, except as noted by me. In the event of illness or accident in the course of such activity, I request that measures be instituted without delay as the judgment of medical personnel dictates.
Signature:________________________________________________________ Date: _________________________