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| Emergency Medical Form (One form required for each occupant of every vehicle) MUST REMAIN IN VEHICLE DURING ANY AND ALL MITSUBISHI FOUR WHEEL DRIVE CLUB OF NORTH AMERICA EVENTS Full Name_____________________________________________________________Phone________________________ Address____________________________________________________________________________________________ City____________________________________________________________State___________Zip__________________ Birth Date________________________________ Physician____________________________________________________Phone__________________________________ Emergency Contact_____________________________________________________Phone__________________________________ Address____________________________________________________________________________________________ City__________________________________________________________State_____________Zip__________________ Pre-Existing Conditions: (Please check all that apply) |
| [ ] kidney or liver disorder [ ] diabetes [ ] hepatitis [ ] smoker [ ] contact lenses [ ] pacemaker |
| [ ] heart trouble [ ] high blood pressure [ ] low blood pressure [ ] anemia [ ] hypoglycemic [ ] emphysema |
| MITSUBISHI FOUR WHEEL DRIVE CLUB OF NORTH AMERICA http://www.geocities.com/mitsubishifourwheeldriveclub |
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| [ ] other (please specify)_______________________________________________________________________________ ___________________________________________________________________________________________________ Allergies: [ ] penicillin [ ] sulfa [ ] bee stings [ ] other (please be specific)_________________________________________________________________________ ________________________________________________________________________________________________ List any medication(s) you are currently taking ____________________________________________________________ ___________________________________________________________________________________________________ List any emergency instructions_________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Please turn over and continue on the reverse side if you run out of any room. Form MFWDC-03A-031302-a |