Ph: (815) 879-3739
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Attention Bus Hop attenders (health form)


Greetings!

If you are joining us on the "Tour de Quilt" bus hop this weekend, please fill out the Health Information and Emergency Authorization and place it in a sealed envelope with your name on the outside and give it to Erin, the bus mom, when you get on the bus on Friday.  The form will be confidentially held by her and will be returned to you upon completion of our hop or destroyed.

Name___________________________________________________

Address__________________________________________________

City__________________State____________Zip______________

Emergency Contact Person_________________________________

Phone__________________________________________________

Significant Medical History ( ex. 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________________________


Remember, the bus will pull out of the parking lot at the back of our store at 6:30 AM on Friday, October 17.  We will look forward to seeing you all bright eyed and bushy-tailed!!!!!!!

TTFN,
Carol and Beth
Quilter's Garden
Princeton, IL
815-879-3739