Medical Information Form: Illinois Miss Amazing
Please provide the following information so that we ensure each participant is safe and understood at Illinois Miss Amazing.
First Name
Your answer
Last Name
Your answer
Attending Physician
Your answer
Physician's address
Street
Your answer
City
Your answer
State
Your answer
Medical condition
Any condition in addition to the diagnosis that may affect abilities. Ex. heart disease, diabetes, asthma, etc.
Your answer
Current Medications
Your answer
Allergies and/ or drug sensitivities
Your answer
Equipment
Does the participant need assistance walking?
Does the participant have seizures?
If yes, type/ length/ frequency
Your answer
Can the participant feed, use the bathroom, and medicate herself?
If not, who will be assisting her?
Name
Your answer
Relationship
Your answer
Phone
Your answer
Emergency Contact #1
Name
Your answer
Relationship
Your answer
Phone
Your answer
Emergency Contact #2
Name
Your answer
Relationship
Your answer
Phone
Your answer
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)
Your answer
Date
Your answer
Submit
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