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Bus Hop Health Form - Please fill out!!!!

Hi Ladies,
Friday morning is almost here!  One last thing to do before you get on the bus.  Please fill out the form and hand it to the bus mom when you get on the bus.

Carol and Beth
Quilter's Garden

Health Information and Emergency Authorization








Emergency Contact Person_____________________________


Phone _____________________________________________


Significant Medical History (asthma, diabetes, heart condition)



Significant Allergies to medications or foods



Current Medications



Physician___________________  Phone__________________________


Emergency Authorization:  I give my permission to local physician to hospitalize, treat, order injections, anesthesia, or surgery if the contact person cannot be reached.




Medical costs incurred while on this event are the sole responsibility of the Participant.  Participant assumes all risk and expense related to accidental injury.  Quilter’s Garden and staff cannot be held liable for any expense or litigation as a result of this event.




Place this form in a sealed envelope with your name on the outside.  The form will be confidentially held by the bus mom and will be returned to you upon completion of our hop.