Thank you for your interest in joining a WGO Serve Team. Please complete this Serve Team Member Emergency Medical Information Form for your team Leader

Team Member Emergency Medical Information Form
Team *
Name *
Gender: *   
Birth Date *
Parent's name
Parent's Phone
HEALTH INFORMATION
To be completed by all participants.
Mark your answer to the following questions. (if yes, Please Explain)
Do you have any drug allergies? *   
Explain
Do you have any food allergies or dietary restricitons? *   
Explain
Do you have any environmental allergies? *   
Explain
Has any allergic reaction require emergency room care? *   
Explain
Do you have a heart condition? *   
Explain
Do you have a high blood pressure? *   
Explain
Do you have respiratory difficulties? *   
Explain
Are you Diabetic? *   
If diabetic, how is your diabetes controlled?
Do your wear contact lenses? *   
Have you had any serious illness or surgery within the past three years? *
Explain
Are you subject to any of the following: if Yes, Please explain?
Fainting? *   
Sleep Walking? *   
Frequent upset stomach? *   
Do you have any condition that would prevent you from participating in any activities? *   
Please Explain any Yes Answers
Please indicate ANYTHING else that the leaders should know to help deal with any situation that might arise.
Other information
List all current medication, the dosage, and why it is being taken.
Please list any other medications that you will be taking with you.
EMERGENCY CONTACT INFORMATION
(Someone NOT with you on this trip)
Name *
Contact relationship *
Contact Street Address *
Contact City,State Postal/Zip Code *
Contact Phone *
Contact Work or Cell Phone
Your primary physician: *
Your Physician's Phone *