Medical Form

Person Details

Student Name(Required)

First Last

Date of Birth(Required)

Student Activity Attending(Required)

Activity attending

Please include name of activity and city

State hosting the event(Required)

Level Attending(Required)

Medic Alert Number (if applicable)

Emergency Contact Name(Required)

Emergency Contact Number(Required)

Health support information

Does you/your child have a health care need that could affect their safety during this activity?

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Details

If yes please provide details below, and how it could affect the activity. Please also provide details of the medication and any treatments or precautions including allergic reactions to medications.

Medications

Please let us know what medications you will have with you so that it may be easily located should the need arise.

Date(Required)

RAD Australia Medical Form AUSTRALIA

Person Details

Health support information