This form must be completed, signed and turned in prior to the start of this program

Name _________________________________________________ Birth Date ___________________ Sex________

Address____________________________________ City________________________ State________ ZIP _______

Do you have a history of, or do you currently have. any physical limitations that might prevent you from fully participating in this program? Yes ____ No ____
If yes, please specify missing or injured bodily parts, weakness, eyeglasses, contacts, hearing aids, etc. _______________

Do you have any learning disability that might prevent you from fully participating in this program? Yes ____ No ____
If yes, please specify________________________________________________________________________________

Please check ( ) those that apply and provide necessary information on reverse side of this form.

Chronic Ailments:
___ Asthma, or other respiratory problems   ___ Insect bites
___ Circulatory or heart problems   ___ Bee stings
___ Diabetes or hypoglycemia   ___ Foods
___ Epilepsy   ___ Drugs
___ Hemophilia. or other bleeding problems   ___ Others, if significant

Current medications or pertinent information _____________________________________________________________

Blood type _________________ Date of last tetanus shot ______________

Family physician name ____________________________________________________ Phone _____________________

Date of most recent physical examination _______________________

Where are your medical records kept? __________________________________________________________________

Insurance Carrier ________________________________________________ Insurance ID # ______________________

Who should be notified in case of emergency?

Name _________________________________________________________ Relation ___________________________

Phones _____________________(Residence) ______________________(Cell) _______________________ (Business)

Name _________________________________________________________ Relation ___________________________

Phones _____________________(Residence) ______________________(Cell) _______________________ (Business)

I, the undersigned, do hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis or procedure rendered under the general or specific supervision of any member of the medical staff or of a dentlst licensed under the provisions of the Education Law and/or Public Health Law of the State of North Carolina and on the staff of any hospital holding a current operating certificate issued by the Department of Health of the State of North Carolina. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power to render care which the aforementioned physician in the exercise of his/her best judgment may deem advisable. It is understood that effort shall be made to contact the above people prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if any of these people cannot be reached.

Signature __________________________________________            Date _______________________