Emergency Medical Form Page 2
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2Participant Name: __________________________________________
Current Medication(s) Taken:
Medical Condition(s):
Any Other Pertinent Information
I understand that this form will be used only in case of an emergency. I authorize the use of this information in order to
secure proper medical attention.
Print Name: _____________________________________________________________________________________________
Signature: ______________________________________________________ Date: __________________________________
Revised 9/21/15
Page 2 of 2
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Parent category: Medical