The Nicholas Center's Emergency Contact, Medical & Waiver Forms
This form must be filled out by all participants and updated annually or as needed.
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Today's Date *
Name of Participant *
Date of Birth *
Participant's Full Residential Street Address  , City , State and Zipcode *
Diagnosis(es) *
List any allergies. If none, note N/A *
Physical restrictions or limitations. If none, note N/A *
List any Medications, dosages and what they are used to monitor/control, If none, note N/A *
List all Doctors,affiliations and numbers to be called in an emergency *
Primary Caregiver 1 : First and Last Name *
Primary Caregiver 1: Email *
Primary Caregiver 1: Home Address *
Primary Caregiver 1: Home Phone Number *
Primary Caregiver 1: Cell Number *
Primary Caregiver 1: Work Number *
Secondary Caregiver 2: First and Last Name *
Secondary Caregiver 2: Email *
Secondary Caregiver 2: Home Address *
Secondary Caregiver 2: Home Phone *
Secondary Caregiver 2: Cell Phone *
Secondary Caregiver 2: Work Phone *
Additional Emergency Contact Name *
Emergency Contact relation to participant *
Emergency Contact Number *
Photo and Video Release: Must Check one *
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