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Health Form
 
Thu, Jun 14, 2007 12:26 pm | Updated Tue, Apr 29, 2008 10:44 am
By Collins Chris

DIVE TEAM

EMERGENCY HEALTH CARE FORM

FAMILY NAME: ______________________________________________________________

Home # ________________ Cell # ___________ E-MAIL:_______________________ ____________________________________________________________

DIVER:

Name: ____________________________ Male/Female: ____ Age: ____ Date of Birth: ___________

Allergies/Medical concerns: ____________________________________________________________

____________________________________________________________________________________

DIVER:

Name: ____________________________ Male/Female: ____ Age: ____ Date of Birth: ___________

Allergies/Medical concerns: ____________________________________________________________

____________________________________________________________________________________

DIVER:

Name: ____________________________ Male/Female: ____ Age: ____ Date of Birth: ___________

Allergies/Medical concerns: ____________________________________________________________

____________________________________________________________________________________

DIVER:

Name: ____________________________ Male/Female: ____ Age: ____ Date of Birth: ___________

Allergies/Medical concerns: ____________________________________________________________

____________________________________________________________________________________

DOCTOR: ____________________________________ DOCTOR S PHONE #: ______________________

INSURANCE: __________________________________ POLICY #: _______________________________

EMERGENCY CONTACT: ______________________________________PHONE #: _________________

PERMISSION:

In the unlikely event of an emergency, when I cannot be contacted, any one of the Canterbury Woods Dive Team Coaches has my permission to take my child to the emergency room of a nearby hospital. Its medical staff has my authorization to provide treatment that a physician deems necessary for the well-being of my child.

Signature: _________________________________________________ Date: ____________________