The New England District of
Circle K
Medical Questionnaire and Emergency Medical Treatment
Authorization Form
Please type
or print. This form is required for all participants attending Convention and
must be completed in full. This form is to be mailed with the registration
form.
(Street) (City) (State) (Zip Code)
Person to be contacted in case of
emergency_________________________________________
Relationship____________ Home Phone
(____)______________Work Phone (____)_________
Alternate
Contact_______________________________________________________________
(Name) (Relationship) (Phone)
Name of Doctor __________________________
Phone Number (____)____________________
Doctor’s
Address______________________________________________________________
Name of Health Insurance Co.
________________________ Policy #______________________
List any pertinent information listed on
medical card __________________________________
PLEASE ANSWER YES OR NO:
1.
Will you be
taking medication of type during the weekend?
____________
2.
Have you
ever been treated for: (If currently
being treated please indicate)
A. Nervousness? ____
H. High Blood Pressure? ____
B. Any mental disorder?
____ I. Severe or Frequent Headaches? ____
C. Convulsions or Epilepsy? ____ J. Asthma? ____
D. Fainting Spells? ____ K.
Ulcers? ____
E. Heart Condition? ____ L. Diabetes? ____
F. Rheumatic Fever? ____ M. Allergic reaction to
medication? ____
G. Cancer or Tumor? ____ N. Any
other allergies or illnesses?
____
3.
Do you have
any other physical limitations? __________
Give
details of yes answers to any of the questions above. Give dates of treatment,
and names and addresses of attending physicians, hospitals and clinics. (Use
reverse side if necessary)
__________________________________________________________________________________________________________________________________________________________
PLEASE READ CAREFULLY:
I
hereby certify that the information given above is correct. In case of medical
emergency, I understand that every effort will be made to contact the person
designated above. In the event that person cannot be reached, or time does not
permit, I hereby give permission to a licensed physician to provide proper
treatment for,
Signature__________________________________________________________Date________