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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