NOTICE TO ALL RIDERS:

To avoid any unnecessary delays, MECTA recommends that you fill out and sign this form.  You should plan to keep a copy of this form accessible to medical personnel in case of emergency.

Name:________________________________

Soc.Sec.# : ___________________________

Date of Birth: __________________________

Address: _____________________________

City: ________________________________

State: _______________Zip: _____________

PERSON TO CONTACT IN CASE OF EMERGENCY:

Name: _____________________________

Telephone: _________________________

Medical Insurance Co.: ________________

___________________________________

Policy No.: __________________________

Member No.: ________________________

MEDICAL INFORMATION:

Prior Medical History: _________________

___________________________________

___________________________________

Allergies: ___________________________

___________________________________

___________________________________

Contact Lenses: _____________________

Medical Doctor: ______________________

Telephone: _________________________

Date of last tetanus shot: ______________

Other: _____________________________

__________________________________

NOTICE TO PARENTS AND GUARDIANS:

In many situations, a minor child cannot receive emergency medical care without the authorization of a parent or guardian.  If you are not going to be present personally at the competition, you should consider using this form in conjunction with your child’s entry.  You should make arrangements for a responsible person accompanying your child to have a copy of this form available to medical personnel if required.

RELEASE FOR AN ADULT RIDER:

If emergency medical care is required for myself and I, or an accompanying spouse or relative, am not able to convey permission in a timely manner, then the undersigned authorizes appropriate emergency medical care as deemed necessary by emergency medical personnel, a physician, or the medical facility providing treatment.

I have read this entire release and agree to it:

Signed: __________________________________

Date: ____________________

RELEASE FOR A MINOR RIDER:

If emergency medical care is required for :

(child’s name)__________________________________

and if permission is not available in a timely manner, then the undersigned authorizes appropriate emergency medical care as deemed necessary by emergency medical personnel, a physician, or the medical facility providing treatment.

I have read this entire release and agree to it:

Signature: ____________________________________

(parent or guardian)

Date: _____________________

EMERGENCY MEDICAL RELEASE FORM