Drivers
Medical Condition Form
Please
complete in full and return with your registration (one form per driver).
Driver
Medical Information Date:_______________
Driver
Name: ______________________________________________________
Age:
_________ Date of Birth:
_______________ Blood Type:
____________
Date
of last Tetanus: _________________________
Prescription
Medications: _____________________________________________
__________________________________________________________________
__________________________________________________________________
Special
Medical Conditions: __________________________________________
__________________________________________________________________
__________________________________________________________________
Insurance
Information:
Carrier:
_______________________________ ID
Number: ________________
Group:
____________________________________________________________
Subscriber:
_________________________________________________________
Emergency
Contact: Is this
person at the Hill ? Yes _____ No _____
Name:
_____________________________________________________________
Relation:
___________________________________________________________
Phone:
_____________________________________________________________
(Alternate
Phone): ____________________________________________________
Other
Info: __________________________________________________________
___________________________________________________________________
___________________________________________________________________
Check
Yes or No, as applicable for each condition
|
|
Yes |
No |
|
Yes |
No |
|
Yes |
No |
|
Contacts |
|
|
Asthmatic |
|
|
Hemophiliac |
|
|
|
Dentures |
|
|
Diabetic |
|
|
Allergies - Penicillin |
|
|
|
Hearing Impaired |
|
|
Hypertension |
|
|
Other Allergies (please list details below
this table) |
|
|
|
Pregnant |
|
|
Epileptic |
|
|
|
|
|