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Antietam CreekConfidential Med Form 


                                    CONFIDENTIAL MEDICAL INFORMATION


If you take medications for allergies bring them with you to the training course.


(Please print clearly)


Name of participant_________________________________________   Male ______   Female ______


Address ____________________________   City ______________   State/Zip ______________


Home Phone _____________________  Work Phone _____________________  


Age _____   Height _______   Weight ______   Hair Color __________   Eye Color _________


Health ins provider ________________________  Policy # ____________  Group # _________


Emergency Contact: __________________________________  Relationship _______________

     Home Phone _____________________  Office Phone ________________________


Name of personal physician ___________________________   Phone _____________________


Allergies  _____________________________________________________________________


Current Medications ________________________________ Year of last tetanus shot ________


Swimming ability _______________________________________________________________


Have you had or do you currently have any of the following:                            (Circle Yes or No)


  • Physical disabilities or limitations                                                                              Yes      No

  • Dizzy spells, fainting, convulsions, persistent headaches                                        Yes      No

  • Shortness of breath or chest pain                                                                               Yes      No

  • Heart, circulatory or blood pressure problems                                                          Yes      No

  • Back, neck, knee or skeletal problems                                                                        Yes      No

  • Operations/major medical procedures in the last year                                             Yes     No

  • History of serious illness.  Hospitalization required?                                                 Yes     No

  • Emotional/mental disorders                                                                                         Yes     No          Any other medical/health conditions which may impact your participation in

        strenuous outdoor activities                                                                                         Yes      No


If you answered Yes to any of the above, please explain in detail (use back of page if necessary):




Additional Info helpful in an emergency _____________________________________________


In addition, I authorize Kenneth A. Guerrant to act on my or my minor child’s behalf in obtaining medical treatment if I am unable to in the event that I become injured or ill while participating in this program; and I understand that I am fully responsible for all expenses incurred for any medical care received.


Signature ________________________________________________   Date ________________

                (Parent must sign if student under 18)


                       ***This form must be given to the instructor at the first class or outing***


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