WESTERN CAROLINA UNIVERSITY

CLUB SPORTS

 

EMERGENCY INFORMATION

NAME: ____________________          SPORT: ____________________

LOCAL PHONE: ____________________  LOCAL ADDRESS:  ____________________

EMERGENCY CONTACT

          NAME:           __________________________________

          ADDRESS:           __________________________________

          PHONE #:          __________________________________

 

HEALTH INFORMATION

Are you allergic to any medication (i.e. Penicillin)? ______________________________

__________________________________________________________________

__________________________________________________________________

 

Are you currently taking any medication? _________ If yes, what type? _______________

__________________________________________________________________

__________________________________________________________________

 

Have you had an allergic reaction to insect stings? _________ If yes, please describe.

__________________________________________________________________

__________________________________________________________________

 

Do you have any special medical problems? _____ If yes, please describe.

__________________________________________________________________

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The above information is correct to the best of my knowledge.

Signature _____________________________ Date _________________________