Adult Participant Information Form

Each adult requesting to attend must complete this form.
This does not guarantee your spot.

Participant Information

First Name:

Last Name:

Primary Phone:         Secondary Phone (optional):

Email address:         Gender:

Emergency Contact

First Name:

Last Name:

Primary Phone:         Secondary Phone (optional):

Relationship:

Jubilation Information

Photo Release: GSSSC may use photos of me.         GSSSC may not use photos of me.

I will abide by the Behavior Agreement.

T-Shirt Size:

Do you have any special accessabiltiy needs? If yes, please briefly explain:

Health History and Medical Information

Name of Physician:

          Physician Phone:

Medical/Hospital Insurance Carrier:

          Policy or Group #:

Dental Insurance Carrier:

          Policy or Group #:

Age: Weight:

Immunizations up to date: Yes   No   N/A         Date of last tetanus shot:

Date of last health examination:

          Were there any problems at the time?

Has the participant had any recent injuries or surgery? Yes   No

          If yes, please explain and specify date:

Is participant restricted or limited from participating in any physical activity? Yes   No

          If yes, please explain:

Participant has the following health conditions:
ADHD/ADD   Asthma   Diabetes   Headaches   Seizures   Other:  

Allergies and treatments:

Medication Information

You must list all prescriptions and over-the-counter medications that you plan to bring with you to the event.

As an adult, you can either turn your medication in to the nurse, or keep them yourself in a locked container (cashbox, backpack with a padlock, etc.).

MEDICATION INFORMATION

DOSAGE

1st

2nd

3rd

4th

Name of Medication:

Reason taking:

Adverse Affects You've Experienced:

How Long You've Taken:

Special Instructions:

When:

Quantity:

Form:

When:

Quantity:

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When:

Quantity:

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When:

Quantity:

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Name of Medication:

Reason taking:

Adverse Affects You've Experienced:

How Long You've Taken:

Special Instructions:

When:

Quantity:

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When:

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When:

Quantity:

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Name of Medication:

Reason taking:

Adverse Affects You've Experienced:

How Long You've Taken:

Special Instructions:

When:

Quantity:

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When:

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When:

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Name of Medication:

Reason taking:

Adverse Affects You've Experienced:

How Long You've Taken:

Special Instructions:

When:

Quantity:

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When:

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When:

Quantity:

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Name of Medication:

Reason taking:

Adverse Affects You've Experienced:

How Long You've Taken:

Special Instructions:

When:

Quantity:

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Name of Medication:

Reason taking:

Adverse Affects You've Experienced:

How Long You've Taken:

Special Instructions:

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Quantity:

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Name of Medication:

Reason taking:

Adverse Affects You've Experienced:

How Long You've Taken:

Special Instructions:

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Name of Medication:

Reason taking:

Adverse Affects You've Experienced:

How Long You've Taken:

Special Instructions:

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Name of Medication:

Reason taking:

Adverse Affects You've Experienced:

How Long You've Taken:

Special Instructions:

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Quantity:

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Name of Medication:

Reason taking:

Adverse Affects You've Experienced:

How Long You've Taken:

Special Instructions:

When:

Quantity:

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