Which week(s) are you attending:

Name:      Date of Birth:      Email:  

Cell phone:      Home Phone:      Work Phone:  

Address:

Height:      Weight (pounds):      Gender:  

Emergency Contact:      Relationship of Emergency Contact:   

Primary Emergency Phone Number (Day):      Primary Emergency Phone Number (Evening):      Primary Emergency Phone Number (Cell):  

Full Address of Emergency Contact:

Health Questionnaire

Parent or legal guardian should complete form for all children under 18 years participating in AMC program.

1. Have you experienced an asthma attack at any time in your life?   

2. Have you ever been diagnosed with type I or type II diabetes?  

3. Have you ever experienced a serious allergic reaction, or have you ever been given a shot of epinephrine for an allergy or anaphylaxis?

4. Have you ever received medical treatment for angina, a heart attack, or any type of heart disorder or disease?  

5. Have you ever been diagnosed with or are you currently being treated for high blood pressure?  

6. Have you ever seen a medical professional following a seizure, or are you currently being treated for any type of seizure disorder?  

7. ls there anything else you think we should know about your medical Background? i.e., anything that could affect your safety or ability to participate fully

Food allergies. What is the type of allergy (ingested or airborne), and how severe is the reaction:  

PLEASE READ CAREFULLY. Participants (and parents/guardians, if appropriate) must read and sign below.

Participant acknowledgment of accuracy and understanding. By signing this form, I am declaring that, to the best of my knowledge, I have completed the questionnaire accurately. I also understand that by knowingly filling out the form inaccurately, or by withholding pertinent information about my health, I could potentially be increasing the risk to myself or others.

Consent to accept aid. By signing this form, I am giving consent and permission for AMC staff, volunteers, representatives, or contractors to provide medical care to me or to my child, to transport me or my child to a medical facility or to seek the aid of emergency medical services as deemed appropriate. I further authorize AMC staff, volunteers, representatives, or contractors to render whatever treatment they consider necessary for my or my child’s health, and I agree to pay all costs associated with that care and transportation.