NO.42 (CITY OF DUNEDIN) SQUADRON

ATTENDANCE FORM:

Date: to     Cost: $
Emergency Contact:     Payment Due Date:
Emergency Commander:

I hereby give permission for (first and last name) ______________________________________________ to attend this activity.
Signed ___________________________________________________________

An all hours contact phone number is __________________________

Payment for this activity is by: (please circle)
Cash     Cheque     Auto-Payment

Medical Details
Name of family doctor (or the doctor to be contacted in the event of a problem): _________________________________________________________________
Doctor’s telephone number: ___________________________ Doctor’s after hour contact: ___________________________

Do you currently have any disease/sickness/injury/allergies/illness/disorder? Y / N
Are you recovering from any medical condition / disorder, as above? Y / N
Are you taking any medication? Y / N
Have you had a reaction to any medical drugs used? Y / N

If the answer to any of the above questions is YES, or if there is any other medical information that may be relevant, please provide details.
1. Type and severity of injury / sickness / disease / operation / allergies / illness / disorder: __________________________________________________________________________________________________________________
2. Restriction on activities: ________________________________________________
3. Medication required (type, amount and frequency): _________________________________________________
4. Medical drugs reacted to: ________________________________________________
5. Other relevant medical information: ________________________________________________

Dietary
Please list any and all dietary requirements. For example vegetarian, allergies etc. __________________________________________________________________________________________________________________