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MEDICAL FILE
Date: October 30, 2024
Please select who will be participating...
Adult
Minor(s)
Adult and Minor(s)
1 Minor
2 Minors
3 Minors
4 Minors
5 Minors
More Minors
6 Minors
7 Minors
8 Minors
9 Minors
10 Minors
Continue
First
Participant's
Name
First Name
*
Middle Name
Last Name
*
First
Participant's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
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- Year -
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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
*
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Close
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Second
Participant's
Name
First Name
*
Middle Name
Last Name
*
Second
Participant's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
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- Year -
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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
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
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- Year -
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1918
1917
1916
1915
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
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
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- Year -
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1918
1917
1916
1915
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
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
2
3
4
5
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- Year -
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1920
1919
1918
1917
1916
1915
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
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
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- Year -
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1915
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
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
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- Year -
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1915
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
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
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- Year -
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1917
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1915
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
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
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- Year -
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1915
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
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
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- Year -
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1915
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
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
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- Year -
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Yes
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No
Yes
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If necessary, will you accept medical treatment?
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No
Yes
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