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Jink & Diddle School of Scottish Fiddling ~ Medical Form

In order to provide the best possible assistance to any Jink & Diddle participant in the event of an emergency, we request that you complete this authorization for your own benefit.  

Please note that the AGREEMENT at the end of this form MUST BE COMPLETED BY THE PARTICIPANT - OR A PARENT, IF THE PARTICIPANT IS A MINOR.  

Full Name

Date of Birth

Social Security Number

Emergency Contact's Full Name

Contact's Telephone Number (1)

Contact's Telephone Number (2)

Contact's Telephone Number (3)

Texting OK on

(1)

(2)

(3)

Emergency Contact Address

Medical conditions for which participant is under a doctor's care?

NoYes

Physical limitations?

Special diet or food allergies?

If taking any medication bring a plentiful supply as it may be difficult to refill prescriptions

Allergic to bee stings or insect bites?

Date of Last Tetanus Immunization

Primary Care Physician

Medical Insurance Policy Information

AGREEMENT

understand that in case of medical emergencies local facilities and/or hospitals will be used.

authorize John W. Turner or his designated representative for the Jink & Diddle School

to authorize treatment for

myselfmy minor child

have agreed to submit this authorization by electronic means.

understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.

By checking this box and typing my name below, I am electronically signing this authorization.

Signature

Relationship to Participant

NOTE - When the screen goes blank after you submit, scroll up to see confirmation that your submission was successful.

Thank you!

We have received your submission. See return link options.

Error

Bad respond

ALL INFORMATION STRICTLY CONFIDENTIAL

The Jink & Diddle School of Scottish Fiddling is an undertaking of Fiddletree Music, Inc.

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