Participant Information 

• Name: _______________________________ 

• Date of Birth: _________________________ 

• Address: ____________________________ 

• Phone: _______________________________ 

• Email: _______________________________ 

 

Emergency Contact 

• Name: ________________________________ 

• Relationship: __________________________ 

• Phone: _______________________________ 

• Alternate Phone: _______________________ 

 

Medical Information 

• Allergies: __________________________________________ 

• Current Medications: ________________________________ 

• Medical Conditions: _________________________________ 

• Physical Limitations: ________________________________

 

I authorize emergency medical treatment if I am unable to provide consent. 

 

Signature: _________________ Date: ________