Recreation Swim Team Participant Health Card
Please note: A separate form MUST be completed for EACH registered participant.
Please indicate which team the swimmer is a participant of: *
Participant's First Name *
Your answer
Participant's Last Name *
Your answer
Participant's Gender *
Participant's Date of Birth *
MM
/
DD
/
YYYY
Participant's Height (in feet and inches) *
Your answer
Participant's Weight (in lbs.) *
Your answer
What would you say is the present state of the participant's physical health? *
Please select one
Participant's Physician First and Last Name *
Your answer
Participant's Physician Phone Number *
Numbers Only - include area code
Your answer
Emergency Contact and Relationship to Participant *
Enter the name and relationship of the person to contact in case of an emergency.
Your answer
Emergency Contact Phone Number *
Enter the phone number of the emergency contact
Your answer
Is the participant presently taking any medication? *
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