Medical Information Form: Idaho Miss Amazing
Please provide the following information so that we ensure each participant is safe and understood at Idaho Miss Amazing.
Sign in to Google to save your progress. Learn more
First Name *
Last Name *
Attending Physician *
Physician's Address *
Street
*
City
*
State
Medical condition
Any condition in addition to the diagnosis that may affect abilities. Ex. heart disease, diabetes, asthma, etc.
Current Medications
Allergies and/ or drug sensitivities
Equipment
Clear selection
Does the participant need assistance walking? *
Does the participant have seizures? *
If yes, type/ length/ frequency
Can the participant feed, use the bathroom, and medicate herself? *
If not, who will be assisting her?
Name
 
Relationship
 
Phone
Emergency Contact #1 *
Name
*
Relationship
*
Phone
Emergency Contact #2 *
Name
*
Relationship
*
Phone
I authorize that all information provided in the attached Miss Amazing Medical Information form is true and accurate. I authorize Miss Amazing Inc. to release the provided effects of the participant’s disability to the overall judging panel. I authorize Miss Amazing Inc. to release all provided information to the participant's buddy so that she can be cared for properly and promptly. I authorize the Miss Amazing Inc. staff to contact emergency personnel and provide necessary information regarding my medical condition to medical personnel in emergencies. I authorize the Miss Amazing Inc. staff to perform first aid and cardiopulmonary resuscitation (CPR) as necessary, following established guidelines by the American Red Cross for the necessity and deliverance of such care. I understand that there are certain risks of physical injury and agree to assume the full risk of any injuries which the participant may sustain as a result of participating in any and all activities associated with the Miss Amazing Pageant. I declare that I waive all claims against Miss Amazing Inc. or the event’s venue(s), its officials, officers, agents, employees and volunteers arising from injuries, including death, damage, or loss which the participant may sustain.
Parent or Guardian's Signature (if participant is a minor or not one's own guardian)
  *
Date
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Miss Amazing, Inc.. Report Abuse
Google Forms