North Dodge
EMERGENCY MEDICAL INFORMATION
Participants Name(s): ____________________________________________________
Date of Birth: __________________________________ Age: ___________________
Home Address: __________________________________________________________
Home/Cell Phone: _______________________________________________________
Parent Email Address: _____________________________________________________
If a minor: Parent/Guardian Name(s) _________________________________________
Parent/Guardian Employer Phone #: _________________________________________
Preferred Hospital: _______________________________________________________
List of Allergies: ________________________________________________________
Emergency Contact Name: _________________________________________________
Emergency Contact Phone: _________________________________________________
Others to call: ____________________________________________________________
Physician:_______________________________________________________________
My General Health is: above average average poor recovering from injury/accident
(Circle one)
Comments:
Release of Liability:
In consideration of the North Dodge Athletic Club allowing me/my child to use these
facilities/participate in organized activities outside of the club. I hereby forever release
the North Dodge Athletic Club, its owners, managers, instructors and staff from all
liability for any and all damages and injuries including death suffered by myself or my
family in connection with the use of these facilities. I understand that my participation is
entirely by my own choice and with the understanding of risk or accidental injuries
involved in any fitness activity and with club.
Signature of participant: _______________________________ Date: _____________
*If participant is a minor parent or guardian must sign Liability Waiver.
