Form-Medical Disclosure
Huntsville Ski Club, Inc.
P.O. Box 1601
Huntsville, AL 35807
Trip Destination ____________________________
Trip Dates: ____________________________
Trip Coordinator: ____________________________
The following emergency information is submitted to aid medical personnel, as well as The Huntsville Ski Club trip leader, in dealing with any medical emergency that should arise during this trip. I will place this infomation in a signed and sealed envelop, and It is understood that the sealed envelope will not be opened unless I am personally unable to communicate with medical staff.
NAME: ________________________________________________________________________
Home Address: _________________________________________________________________
On-Site Emergency Contact: ______________________________________________________
Relationship: __________________________________________
Home Emergency Contact: ________________________________________________________
Relationship: __________________________________________
Phone Number(s):______________________________________
Chronic Conditions (high blood pressure, diabetes, etc.): ________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Medications (prescription, non-prescription, herbal and dietary supplements):______________ ______________________________________________________________________________ ______________________________________________________________________________
Allergies (drug, food, other like bee sting or latex):_____________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Insurance Company: __________________________________________________
Contact Phone Number: _________________________________________
I attest that this information is accurate and that I have granted permission to Huntsville Ski Club to share it with medical personnel if I am personally unable to do so.
Signature: _______________________________________Date:_______________