Medical Information Form 2010-2011

(to print, right-click this page and select print)

Please Mail Medical Information Form to:

Shandra Richardson

6712 Jackpin Place

Gainesville, VA 20155

SWIMMER(S) NAME (Please fill out per family)

LAST NAME

FIRST NAME(s)

STREET

CITY

STATE

ZIP

HOME PHONE

FATHER WORK

MOTHER WORK

FATHER CELLULAR

MOTHER CELLULAR

FAMILY EMAIL

EMERGENCY CONTACT #1

EMERGENCY PHONE #1

EMERGENCY CONTACT #2

EMERGENCY PHONE #2

PREFERRED HOSPITAL:

DOCTOR'S NAME:

LIST ALL MEDICATIONS PRESENTLY TAKEN BY THE SWIMMER WITH ANY POSSIBLE SIDE EFFECTS:

LIST ANY ADDITIONAL INFORMATION THAT COULD AFFECT THIS SWIMMER:

By my signature, I (_____________________________________) authorize RST to seek immediate medical attention for my child(ren).