BLOOD TYPE (SPECIFY)_____________________________BLOOD PRESSURE:HIGHLOW| NAME________________________________________ | ||
| ADDRESS_____________________________________ | ||
| CITY___________ | STATE____ | ZIP CODE______ |
| PHONE (���)____________________________________ | ||
| SOCIAL SECURITY # _________--_____--__________ | |
| BIRTHDATE ____________ | RELIGION ____________ |
| DOCTOR __________ | TELEPHONE (���)___________ |
| PERSON TO NOTIFY___________________________ | |
| PHONE: HOME (���)__________ | WORK(���)__________ |
| BLOOD TYPE (SPECIFY)_____________________________ |
||
| BLOOD PRESSURE: |
HIGH |
LOW |
| ALLERGIES: |
PENICILLIN |
SULFA DRUGS |
| OTHER (SPECIFY)___________________ |
||
| DIABETES |
EMPHYSEMA |
ASTHMA |
HEPATITIS |
| OTHER DISORDERS ________________________________ |
|||
| _____________________________________________________ | |||
| _____________________________________________________ | |||
| CURRENT MEDICATIONS ____________________________ |
|||
| _____________________________________________________ | |||
| The foregoing information is true and correct to the best of my knowledge. I hereby agree to hold the above-named company harmless from any and all claims, demands or liabilities for whatever reason, including said company's negligence or that of any attending medical personnel. Parent or Guardian must sign separately on behalf of a minor. | |
| ____________________________ | _______________ |
| SIGNATURE | DATE |
| IMPORTANT* | For best results print large with BLACK felt tip marker. Take your time, do it right, it may save your life. This form will not be altered in any manner. |