Loading...

MEDICAL FILE

Date: December 30, 2024

First Participant's Name

First Name*

Middle Name

Last Name*
First Participant's Date of Birth*
First Participant's Information

Age: *
Do you have any medical conditions we should know about?*
No
Yes

If yes, please explain:
Have you had any recent injuries or medical procedures?*
No
Yes

If yes, please explain:
Are you taking any medications?*
No
Yes

If yes, please explain:
Are you allergic to any medications?*
No
Yes

If yes, please explain:
Do you have any food allergies?*
No
Yes

If yes, please specify:
If necessary, will you accept medical treatment?*
No
Yes
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Age: *
Do you have any medical conditions we should know about?*
No
Yes

If yes, please explain:
Have you had any recent injuries or medical procedures?*
No
Yes

If yes, please explain:
Are you taking any medications?*
No
Yes

If yes, please explain:
Are you allergic to any medications?*
No
Yes

If yes, please explain:
Do you have any food allergies?*
No
Yes

If yes, please specify:
If necessary, will you accept medical treatment?*
No
Yes
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Age: *
Do you have any medical conditions we should know about?*
No
Yes

If yes, please explain:
Have you had any recent injuries or medical procedures?*
No
Yes

If yes, please explain:
Are you taking any medications?*
No
Yes

If yes, please explain:
Are you allergic to any medications?*
No
Yes

If yes, please explain:
Do you have any food allergies?*
No
Yes

If yes, please specify:
If necessary, will you accept medical treatment?*
No
Yes
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Age: *
Do you have any medical conditions we should know about?*
No
Yes

If yes, please explain:
Have you had any recent injuries or medical procedures?*
No
Yes

If yes, please explain:
Are you taking any medications?*
No
Yes

If yes, please explain:
Are you allergic to any medications?*
No
Yes

If yes, please explain:
Do you have any food allergies?*
No
Yes

If yes, please specify:
If necessary, will you accept medical treatment?*
No
Yes
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Age: *
Do you have any medical conditions we should know about?*
No
Yes

If yes, please explain:
Have you had any recent injuries or medical procedures?*
No
Yes

If yes, please explain:
Are you taking any medications?*
No
Yes

If yes, please explain:
Are you allergic to any medications?*
No
Yes

If yes, please explain:
Do you have any food allergies?*
No
Yes

If yes, please specify:
If necessary, will you accept medical treatment?*
No
Yes
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Age: *
Do you have any medical conditions we should know about?*
No
Yes

If yes, please explain:
Have you had any recent injuries or medical procedures?*
No
Yes

If yes, please explain:
Are you taking any medications?*
No
Yes

If yes, please explain:
Are you allergic to any medications?*
No
Yes

If yes, please explain:
Do you have any food allergies?*
No
Yes

If yes, please specify:
If necessary, will you accept medical treatment?*
No
Yes
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Age: *
Do you have any medical conditions we should know about?*
No
Yes

If yes, please explain:
Have you had any recent injuries or medical procedures?*
No
Yes

If yes, please explain:
Are you taking any medications?*
No
Yes

If yes, please explain:
Are you allergic to any medications?*
No
Yes

If yes, please explain:
Do you have any food allergies?*
No
Yes

If yes, please specify:
If necessary, will you accept medical treatment?*
No
Yes
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Age: *
Do you have any medical conditions we should know about?*
No
Yes

If yes, please explain:
Have you had any recent injuries or medical procedures?*
No
Yes

If yes, please explain:
Are you taking any medications?*
No
Yes

If yes, please explain:
Are you allergic to any medications?*
No
Yes

If yes, please explain:
Do you have any food allergies?*
No
Yes

If yes, please specify:
If necessary, will you accept medical treatment?*
No
Yes
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Age: *
Do you have any medical conditions we should know about?*
No
Yes

If yes, please explain:
Have you had any recent injuries or medical procedures?*
No
Yes

If yes, please explain:
Are you taking any medications?*
No
Yes

If yes, please explain:
Are you allergic to any medications?*
No
Yes

If yes, please explain:
Do you have any food allergies?*
No
Yes

If yes, please specify:
If necessary, will you accept medical treatment?*
No
Yes
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Age: *
Do you have any medical conditions we should know about?*
No
Yes

If yes, please explain:
Have you had any recent injuries or medical procedures?*
No
Yes

If yes, please explain:
Are you taking any medications?*
No
Yes

If yes, please explain:
Are you allergic to any medications?*
No
Yes

If yes, please explain:
Do you have any food allergies?*
No
Yes

If yes, please specify:
If necessary, will you accept medical treatment?*
No
Yes
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
PARENT’S OR GUARDIAN’S ADDITIONAL INDEMNIFICATION (Must be completed for participants under the age of 18 ) In consideration of minor(s) (“Minor”) being permitted by El Bloque to participate in its activities and to use its equipment, I further agree to indemnify and hold harmless El Bloque from any and all claims which are brought by, or on behalf of Minor, and which are in any way connected with such use or participation by Minor.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Age: *
Do you have any medical conditions we should know about?*
No
Yes

If yes, please explain:
Have you had any recent injuries or medical procedures?*
No
Yes

If yes, please explain:
Are you taking any medications?*
No
Yes

If yes, please explain:
Are you allergic to any medications?*
No
Yes

If yes, please explain:
Do you have any food allergies?*
No
Yes

If yes, please specify:
If necessary, will you accept medical treatment?*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE! and  Rock Gym Pro