Participant Waiver And Hold Harmless Form (Page 3 of 3) in pdf

Participant Waiver And Hold Harmless Form Page 3

PERSON(S) TO NOTIFY IN CASE OF EMERGENCY

___________________________________________________________________________

Name and Relationship

___________________________________________________________________________

Street Address

___________________________________________________________________________

City, State, Zip Code

___________________________________________________________________________

Day & Evening Phone Number + Area Code

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LABORATORY & FIELD TRIP EMERGENCY INFORMAITON

Name: ________________________________________DT Immunization Date: __________

Next of kin: ____________________________________Relationship: __________________

Next of kin address: __________________________________________________________

Next of kin phone number: _____________________________________________________

List allergies: ________________________________________________________________

Chronic conditions: ___________________________________________________________

Current medications: __________________________________________________________

Personal physician: ___________________________________________________________

Physicians phone number: _____________________________________________________

Are you currently certified in CPR? ______________

Participant Waiver And Hold Harmless Form Page 3