Medical Form

Hi!

This is the medial form in which every person in our production team has to fill out for health and safety purposes.

Name: …………………………………………..

Address: ………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

Date of Birth: ………………………..

Age: ………………………….                                 Sex: M/F

If under 18:

Name of parent/guardian: …………………………………………………………………..

Home Telephone: ……………………………………….

Mobile/ Work Telephone: ……………………………………..

Emergency Contact: (If person above is not available in case of emergency)

Name: ………………………….        Relationship: …………………………..  Contact: ……………………

Medication

Do you take any form of medication: Yes/No

If yes, please state below:

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

How often do you take this medication and at what dose:

………………………………………………………………………………………………………………………

Do you have any allergies: Yes/No

If Yes, please state what below:

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

If they have any other medical issues, please state below:

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

(If over 18): I agree to look after myself and my medication and take it in case of emergency or get a fellow member of the team to assist me:

Signed: ……………………………………………            Date: ……………………………………………..

(If under the age of 18):  I agree that my son/daughter to take care of their medicine themselves and to take it when needed and also I allow any of my team members to help me in case of emergency:

Signed………………………………………………         Date: ……………………………………………

See you soon!