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| NEW FAIRFIELD SUNSHINE CENTER MEDICAL EMERGENCY FORM Please Print Name ____________________________________ Birthdate: ___________ Home Phone: _____________ Address: _________________________________________ _________________________________________________ Medications currently used: _____________________________________________________________________________ Allergies: ____________________________________________ Any Medical Conditions that we need to be aware of: ______________________________________________________ Primary Care Doctor Name:_______________________ Telephone number:_______________________ Person to be notified in case of emergency: Name: __________________________________ Relationship:_____________________________ Telephone number: ______________________ Signature:___________________________ Date: _______ Completed emergency medical form is required for all New Fairfield Senior Center Trip participants Completed Health forms are for the New Fairfield Senior Center travelers to be used in case of health emergency only and otherwise will be kept private at all times |