Blazesports Bsa Participant Medical Information Form
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Participant Name ________________________________________________________
Doctors Name __________________________ Doctor Number __________________
Emergency Contact Name________________________________________________
Emergency Contact Number______________________________________________
Primary Medical Insurance Company ______________________________________
Policy Holder (name) ________________________ Policy Number ______________
Primary Disability___________________________ Date of Onset _______________
Secondary Disability ________________________Date of Onset ________________
Date of Last Tetanus Shot ______________
Are all of your immunizations up to date? Yes
No If not, please specify which
immunizations are currently not up to date:
Do you have any allergies( i.e. latex) Yes
No
If so, please be specific in describing the symptoms of an allergic reaction:
Current Medications (include name and dosage):
Please list any previous surgeries and dates on which they were preformed:
Date
Date
Date
535 North McDonough Street | Decatur, Georgia 30030 | 404.270.2000 main | 404.270.2039 fax |
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Parent category: Business