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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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* Required
Today's Date
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MM
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DD
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YYYY
Name of Participant
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Your answer
Date of Birth
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MM
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DD
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YYYY
Participant's Full Residential Street Address , City , State and Zipcode
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Your answer
Diagnosis(es)
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Your answer
List any allergies. If none, note N/A
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Your answer
Physical restrictions or limitations. If none, note N/A
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Your answer
List any Medications, dosages and what they are used to monitor/control, If none, note N/A
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Your answer
List all Doctors,affiliations and numbers to be called in an emergency
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Your answer
Primary Caregiver 1 : First and Last Name
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Your answer
Primary Caregiver 1: Email
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Your answer
Primary Caregiver 1: Home Address
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Your answer
Primary Caregiver 1: Home Phone Number
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Your answer
Primary Caregiver 1: Cell Number
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Your answer
Primary Caregiver 1: Work Number
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Your answer
Secondary Caregiver 2: First and Last Name
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Your answer
Secondary Caregiver 2: Email
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Your answer
Secondary Caregiver 2: Home Address
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Your answer
Secondary Caregiver 2: Home Phone
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Your answer
Secondary Caregiver 2: Cell Phone
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Your answer
Secondary Caregiver 2: Work Phone
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Your answer
Additional Emergency Contact Name
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Your answer
Emergency Contact relation to participant
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Your answer
Emergency Contact Number
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Your answer
Photo and Video Release: Must Check one
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Yes, Nicholas Center may use photos and videos of the participant,for promotional Print, Press, Radio and Social Media Outlets
No, please do not use photos or videos of the participant in any capacity.
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