Drop-In Emergency Information Form

Participant's Name *
Participant's Name
Address
Address
Phone *
Phone
Date of Birth *
Date of Birth
Does this person take The Ride? *
I understand pick up time is between 8:15 and 8:30pm. *
Emergency Contact Person *
Emergency Contact Person
Emergency Contact Phone *
Emergency Contact Phone
Emergency Contact Address
Emergency Contact Address
If none, please write "none."
If none, please write "none."
Does this participant have seizures? *
Date of last seizure:
Date of last seizure:
Legal Guardian Name *
Legal Guardian Name
Legal Guardian Phone *
Legal Guardian Phone
Legal Guardian Address
Legal Guardian Address
Primary Care Physician *
Primary Care Physician
Primary Care Physician Phone *
Primary Care Physician Phone
Date of Last Physical
Date of Last Physical
Note: Data provided on this form is for information purposes only. In an event of an emergency, this form will be given to medical personnel. NWW Committee is not authorized to administer any medications. If this individual does not take medication please write "no medication."