NERO® Medical History & Emergency Information 2006

VORPL activities, like any active sport, involve a certain risk of injury. In the unlikely event that a participant is injured, VORPL would like to take the appropriate actions. Please fill out this form completely and legibly. The information on this form is required for admission into any US hospital. The information will be held in strict confidence.

Participant Name (please print): _____________________________________

Parent or Legal Guardian (please print): _______________________________(if under 18 years of age)

Does the participant have any medical conditions that VORPL needs to know about to ensure the participants safety in the event medical treatment is needed? If yes, please list.

Include allergies (including bee stings), adverse reactions to any medical drugs, asthma, diabetes, fainting spells, heart trouble, convulsions, bleeding disorders, or any other problems.

No _____ Yes _____(please explain)

__________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________

This health history is correct as far as I know, and the person herein has permission to engage in all prescribed activities. In the event I, or the person listed below, cannot be reached in an emergency, I hereby give permission to have 1) VORPL NERO members render first aid, and 2) any physician hospitalize, secure proper anesthesia, or order injection for (participant's name).

____________________________________ (print name) _________________________________________ (Signature)

Date:____________________________ Signature of Parent or Guardian (if under 18), or Participant (if 18 or older)

Parent or Guardian Phone Number: (___) ____________

In case of emergency contact (or enter NONE):

Name:____________________________________ Relationship:_______________________________

Address:_______________________________________ Phone:(____)__________________________

Medical Insurance Information (Plan or Policy Number): _______________________________________

Family Doctor:__________________________________ Phone:(____)___________________________