MEDICAL INFORMATION FORM
FIRST AND LAST NAME
AGE
DATE OF BIRTH SEX
EMERGENCY CONTACT INFORMATION:
Please list the people with you at this gathering and their cabins or tent numbers, that know of your medical conditions and may be of help!
Please tell us who to contact that is not with you at this gathering and their telephone numbers in case of an emergency.
Please provide your physician's name, address, telephone numbers, city and state.
Please list all of your medical conditions!
Please list all of your ongoing symptoms.
Please list all of your medications, dosage and strength.
Please list any allergies you have such as food, insects, medications etc.
Do you take nitro glycerin pills or use a nitroglycerin patch?
YES
NO
Do you use any other type of medicine patch, heart monitor, oxygen,  etc. if so please explain.
In case of an emergency, what should we do to help you while waiting for the paramedics?
Please provide any additional information you feel we should have relating to your medical conditions.
HOME
The Southern Delta Church of Wicca-ATC and it's staff have individuals trained in CPR to assist in the health of festival participants.  Please ask when checking into the festival to sign the form authorizing them to assist you should the need arise.
PLEASE MAKE SURE YOU HAVE COMPLETED ALL THE ABOVE INFORMATION BEFORE CLICKING THE SUBMIT BUTTON!
The Southern Delta Church of Wicca-ATC reserves the right to refuse service to anyone!
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