Download NORTHRIDGE SWIM CLUB

NORTHRIDGE SWIM CLUB
2013 HOUSEHOLD/MEDICAL STATEMENT AND
CONSENT TO MEDICAL CARE & TREATMENT
This form must be on file at the pool before your family may swim.
Family Name:________________________________________________
Primary Phone: ____________________
(Print Name)
Home Address: _______________________________________________ Alternate Phone:____________________
City
Zip
E-mail:_________________________________
Alternate Phone: ____________________
List All Household Member Names (please list birth dates of children under age 18):
______________________________________
___________________________________________
______________________________________
___________________________________________
______________________________________
___________________________________________
______________________________________
___________________________________________
I,
am the parent or guardian having legal custody of the above named child(ren). I authorize all medical, surgical,
diagnostic and hospital care or procedures which may be performed or prescribed for my child(ren), by a licensed physician or
hospital, when efforts to contact me are unsuccessful, and when deemed necessary or advisable by the physician to safeguard my
child(ren)’ s health.
_____________________________
Date:
_____________________________________
SIGNATURE of Parent / Legal Guardian :
__________________________________________________________________________________________________________
(Circle One)
Emergency contact other than above family:
Name: _______________________________Phone: ________________ Work Phone: ________________
Address: ______________________________________________________Relationship: ____________________
Physician name: ____________________________________ Phone: ____________________________
Physician address: _____________________________________________________________________________
Indicate any/all condition(s) that apply to your child(ren) by listing their name(s) next to it.
eyesight impairment ________________________
hearing impairment_____________________________
speech impairment__________________________
sinusitis ______________________________________
kidney disease _____________________________
heart disease___________________________________
abnormal blood pressure _____________________
ear infection ___________________________________
diabetes __________________________________
convulsions ___________________________________
hay fever _________________________________
insect sting reaction _____________________________
asthma ___________________________________
food allergy ___________________________________
regular medication (list)________________________________________________________________________________
other allergy or condition _______________________________________________________________________________
Previous operations or serious injuries (list dates) ____________________________________________________________
____________________________________________________________________________________________________
Immunizations up-to-date for each child? ___________________________________________________________________
Please list any other pertinent information below:
All information on this form is kept confidential.
Please return this form with your membership fee to receive your2013 door combination.
Mail to: Northridge Swim Club, 811 NE 201 st Street, Shoreline, WA 98155