Name:

Address:
Date of Birth:

Age:

Sex:

If under 18:
Name of parent/guardian:
Home telephone:

Mobile/work telephone:

Emergency contact (if person above is not available in case of an emergency):

Name:

Relationship:

Contact:

Medication:
Do you take any medication? Yes/No.
If yes, please state the medication you take and why you take it:

How often do you take this medication and at what dosage?

Do you have any allergies? Yes/No.

If yes, what allergies do you have?

Any other medical issues you think we may need to know about?

{If over 18} - I agree to look after my medication myself and take my medication when I
need it or if in an emergency allow one of the team members to give me my medicine.
{If under 18} - I agree for my son/daughter to take care of their medication themselves
and take it when they need it, and I also allow any team members to give them their
medication in case of an emergency.

Parent/Guardian signature

Date: