EMERGENCY MEDICAL FORM

Name______________________________________________ Birth Date___________________

Address_______________________________________________________________________________

Street City State Zip Code

Phone___________________ ___________________ ___________________ _________________

Home Mom/s Cell Dad’s Cell Work

Physician Name and Phone Number_________________________________________________________

Medical Conditions or Physical Limitations that might prevent you from fully participating in the VYBA program? Circle NO or any that may apply Asthma Heart Condition Diabetes Hypoglycemia

Seizure Disorder Other________________________

Learning Disabilities that might require a bit more help from the instructors: Circle NO or any that may apply Hyperactivity ADD Dyslexia Other_____________________________________________

Physical Aids (Circle) Eyeglasses Contacts Hearing Aids Other___________________________

Allergies (Circle) Insect Bites Bee Stings Foods Medicines Other______________________

Please list details if any of the above is circled ________________________________________

Date of Last Tetanus Shot________________

Parents or Legal Guardian_________________________________________________________________

Address if different from Child___________________________________________________________

Emergency Phone Contact __________________________________ Relationship___________________

Phone__________________ _______________________ ____________________________

Home Cell Work

Emergency Phone Contact _________________________________ Relationship___________________

Phone__________________ _______________________ ____________________________

Home Cell Work

I, ______________________________, authorize the VYBA program organizers, or instructors, to approve emergency treatment for ____________________________in my absence. It is understood that every possible effort is to be made initially to contact me or my Emergency Contacts listed above.

Signature____________________________________________ Date_____________________________

Parent or Guardian

*******ATTACH A COPY OF YOUR MEDICAL INSURANCE CARRIER CARD *******