Permission / Assumption Of Risk / Release Form Page 3
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3EMERGENCY MEDICAL FORM
Community Bicycle Center
Health History and Examination Form for Youth
Information on this form is gathered to assist us in identifying appropriate care.
Name:______________________________________________________________Birthdate_______________Sex______Age____
b
Last
First
MI.
Parent/Guardian:___________________________________________________________________________________________
Home ______________________________________________________________________________Phone #_________________
Street & Number
City
State
Zip
Cell phone # _________________
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Second Parent/Guardian or Emergency Contact:__________________________________________________________________
Home _____________________________________________________________________________Phone #_________________
Street & Number
City
State
Zip
Cell Phone #_________________
Health History:
(Check & Give approx. dates)
Diseases
Allergies (dates not needed)
_________Frequent ear infections
_________ Chicken Pox
________ Hay Fever
_________Heart Defect/Disease
_________ Measles
________ Ivy Poisoning, etc.
_________Convulsions
_________ German Measles
________ Insect Stings
_________Diabetes
_________ Mumps
________ Penicillin
_________Bleeding/Clotting Disorders
________ Other Drugs
_________Hypertension
________ Asthma
_________Mononucleosis
________ Others (specify)
Operations or serious injury (dates)_______________________________________________________________________________
____________________________________________________________________________________________________________
Chronic or recurring illness or medical condition ____________________________________________________________________
____________________________________________________________________________________________________________
Dietary restrictions ____________________________________________________________________________________________
Current medications (parent/guardian needs to bring meds in original container with instructions)
____________________________________________________________________________________________________________
Any physical or emotional challenges that may interfere with activity? ___________________________________________________
Name of Family Physician ______________________________________________________Phone #: ________________________
Name of Dentist/Orthodontist ___________________________________________________ Phone #: ________________________
Do you carry family medical/hospital insurance? YES / NO
If so, indicate: Carrier _____________________________________________ Policy or Group # _____________________________
*MUST BE COMPLETED FOR ATTENDANCE
This heath history is correct so far as I know, and the person herein described has permission to engage in all prescribed activities
except as noted. Authorization for Treatment: I hereby give permission to the medical personnel to order X-rays, routine tests,
treatment to release any records necessary for insurance purposes and to provide or arrange necessary related transportation for me/or
my child/ward. In the event I cannot be reached in an emergency, I hereby give permission to the physician to secure and administer
treatment, including hospitalization, for the person named above.
Signature of parent/guardian _______________________________________Date: _____________________
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