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  • Toledo Quidditch Emergency Contact Form

    Uploaded by

    HishamAbad
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    1. This document collects contact and medical information from a member of a rocket club. It requests the member's name, Rocket ID number, email, phone numbers, emergency contacts, insurance information, and answers to questions about medical conditions. 2. General medical information sought includes allergies, medications, respiratory issues, head injuries, and other problems important for emergency response like diabetes or prior injuries. 3. The member is also asked if they wear contacts, and if so during competition, as well as the type of contacts used.

    Original Description:

    Emergency Contact Form that must be filled out and turned into Toledo Quidditch.

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    1. This document collects contact and medical information from a member of a rocket club. It requests the member's name, Rocket ID number, email, phone numbers, emergency contacts, insurance information, and answers to questions about medical conditions. 2. General medical information sought includes allergies, medications, respiratory issues, head injuries, and other problems important for emergency response like diabetes or prior injuries. 3. The member is also asked if they wear contacts, and if so during competition, as well as the type of contacts used.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    19 views1 page

    Toledo Quidditch Emergency Contact Form

    Uploaded by

    HishamAbad
    1. This document collects contact and medical information from a member of a rocket club. It requests the member's name, Rocket ID number, email, phone numbers, emergency contacts, insurance information, and answers to questions about medical conditions. 2. General medical information sought includes allergies, medications, respiratory issues, head injuries, and other problems important for emergency response like diabetes or prior injuries. 3. The member is also asked if they wear contacts, and if so during competition, as well as the type of contacts used.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Date: _______ / _______ / __________ mm dd yyyy

    ___________________________________
    Member Name

    __________________________ ___________________________________ ______ /_______ /________


    Rocket ID#

    Alternate E-mail Address (Other than @rockets.utoledo.edu)

    ________________________________________________
    ________________________________________________

    Date of Birth (mm/dd/yyyy)

    (______) _______________________
    Phone Number

    Address

    Who to notify in Case of Emergency?


    ______________________________________
    Name Relationship

    _________________________________________________________________
    _________________________________________________________________
    Address City/State, Zip Code

    (____) ______________________ (____) ______________________ (____) ______________________


    Cell Phone Number

    Home Phone Number

    Work Phone Number

    Insurance Information
    ____________________________________________________
    ____________________________________________________
    Policyholder Name Relationship to Club Member

    ____________________________________________________
    ____________________________________________________
    Insurance Company Policy #

    ____________________________________________________
    ____________________________________________________
    Group # Expiration Date

    General Information (circle or explain)


    Disclosure of the following information is voluntary, but helpful in providing medical care if necessary.
    Y N Do you wear contact lenses, do you wear them during competition? Type of lenses: Hard or Soft (circle one)
    Y N Do you have any allergies? If YES, please list below:
    ______________________________________________________________________________________
    Y N Are you taking any prescribed medications regularly? If YES, please list below:
    ______________________________________________________________________________________
    Y N Do you have any respiratory problems? If YES, please list below:
    ______________________________________________________________________________________
    Y N Have you ever suffered a head injury? Y N If Yes, was it severe enough to see a doctor?
    Y N Do you have any medical problems or history of injury that would be important for us to know? ( e.g. diabetes,
    high blood pressure, epilepsy, dislocated shoulder, injured knee, etc.)

    ______________________________________________________________________________________
    ______________________________________________________________________________________

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