Western Carolina University

Sport Club

Emergency Information

 

 

Sport Club: _______________________

 

 

           

 

Name: _____________________________

 

Local Phone #:  _____________________           Local Address: _______________________

 

 

           

 

EMERGENCY CONTACTS:

 

1.                  Name: _____________________________

Address: ___________________________

Phone #: ___________________________

 

2.                  Name: _____________________________

Address: ___________________________

Phone #: ___________________________

 

 

HEALTH INFORMATION:

 

1.                  Are you allergic to any medication (ie penicillin, etc.? _____

If so, what type? ______________________________

                         

2.                  Are you currently taking any medications? ______

If so, what type? ______________________________

 

3.                  Have you had any allergic reaction to insect stings? _____________

If yes, please describe: ____________________________

 

4.                  Do you have any special medical problems?

 

 

 

 

           

 

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

 

Signature: ___________________           Date: ____________________