STUDENT MEDICAL INFORMATION

This form must be completed in full to participate in classes, camps or events.

• What program have you registered for?

  WeeKick Youth Karate Adult Karate Summer Camp Workshop
  

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• Participant First Name

  Participant Last Name
  

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• Participant Email Address
  

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• Mobile Phone
  

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• Participant Birthdate
  

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• Personal Pronouns (ie: she/her, he/him, they/them)

  She/Her He/Him They/Them Other
  

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• Are vaccinations up-to-date? (Does not include Covid)

  YesNo
  

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• Is the participant CURRENTLY INJURED?

  NoYes - Describe at bottom of form
  

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• Does the participant have any ALLERGIES?

  NoYes - Describe at bottom of form
  

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• Does the participant have any BREATHING ISSUES?

  NoYes - Describe at bottom of form
  

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• Has the participant been diagnosed with HIGH/LOW BLOOD PRESSURE?

  NoYes - Describe at bottom of form
  

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• Does the participant have a history of NOSEBLEEDS?

  NoYes - Describe at bottom of form
  

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• Is there a history of CONCUSSION(S)?

  NoYes - Describe at bottom of form
  

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• Does the participant experience CHRONIC PAIN?

  NoYes - Describe at bottom of form
  

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• Does the participant wear a MEDIC ALERT?

  NoYes - BraceletYes - Necklace
  

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• Has the participant had SURGERY in the past 12 months?

  NoYes - Describe at bottom of form
  

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• Does the participant have any concerns with ADD/ADHD/ASD or similar?

  NoYes - Describe at bottom of form
  

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• Provide all MEDICATION information:
  

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• Provide any details from above YES selections:
  

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• Emergency Contact Name 1

  Emergency Contact Phone 1
  

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• Signing FIRST Name

  Signing LAST Name
  

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• Date completed and signed:

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• Signature

  All information is kept confidential and will only be disclosed in the event of a medical emergency or if first aid treatment is required.

  I declare that I have correctly completed this form to the best of my knowledge. I am aware that Driftwood Martial Arts Inc. will not be responsible for injuries due to non-disclosure of information. I understand that it is my responsibility to keep Driftwood Martial Arts Inc. advised of any changes to the information provided.

  

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