Emergency Contact – Thunder Bay Field Naturalists Club

Instructions:

Please complete a separate form for each youth participant. Please keep a copy of your completed form for reference.

Your email address: *

Confirm Your email address: *

Participant Name: *

Date of Birth: *

Health Card #: *

Version Code:

Allergies: *

Yes

No

Types of Allergies:

Please list any other medical conditions that event leaders should be aware of:

Other Medical Conditions

Please fill in the table below with any medications the participant takes regularly:

Medication

Type

Where Kept?

Med-1

Type-1

Kept-1

Med-2

Type-2

Kept-2

Med-3

Type-3

Kept-3

Med-4

Type-4

Kept-4

Med-5

Type-5

Kept-5

Types of medication include: Injector, Inhaler, Pills/Capsules, etc.

Where Kept: e.g. Jacket pocket, Backpack, etc..

This information is used to help the event leader find the medication in case of an emergency.

Are there any accommodations this individual requires to participate in events? *

Yes

No

Accommodations:

Emergency Contacts:

Primary Contact:

First and Last Name: *

Phone *

Relationship to Participant: *

Secondary Contact:

In case the person above cannot be reached.

First and Last Name

Phone

Relationship to Participant

Is another participant emergency registration form required? (Select "Yes" if there is another participant who requires completion of this form) *

Yes

No