Rotary Teton Hillclimb

 

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