Ph: (815) 879-3739
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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.

Thanks,
Carol and Beth
Quilter's Garden
815-879-3739

Health Information and Emergency Authorization

 

Name_____________________________________________

 

Address____________________________________________

 

City_________________________State________Zip_______

 

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.

 

Signature_________________________Date_____________________

 

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.

 

Signature____________________________Date__________________

 

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.