plus50 Health and Emergency Information

First Name: *

Last Name: *

Address: *

City: *

State: *

Zip Code: *

Phone: *

Gender:

Male

Female

Birth Date: *

Health/Special Needs Information: *

Do you have any health conditions (e.g., allergies, chronic conditions) or special circumstances (e.g., religious convictions or legal arrangements) which may affect program participation or that we should know about prior to emergency treatment? (include any foods you may be allergic to)

Medications: *

List any medications you are currently taking: and for what: (if you are on medication, please make sure you bring what you need for the day you are traveling)

Date of last Tetanus: *

Emergency Information

Whom should we notify in case of an accident or medical emergency? (Please include contact information for anytimeof day or night – i.e., cell phone number)

Name: *

Relationship: *

Address: *

Phone: *

Physician: *

Phone: *

Name of health/accident insurance carrier/s and appropriate policy number/s:

Name of Carrier : *

Policy Number: *

Name of Carrier :

Policy Number:

I give permission: *

Yes

I give my permission to for a DCC representative to seek medical assistance in case of an accident/emergency. I understand DCC will not be held liable in case I meet with an accident/emergency.

I understand, if medical assistance (emergency room, doctor visit, etc.) is necessary while I am attending the DCC Plus 50 program, and/or while in transit to or from the program, that I am responsible for all monetary charges for such services.

CAPTCHA

This question is for testing whether you are a human visitor and to prevent automated spam submissions.

Future Students

Main Menu

Quick Links

Quick Links

I give my permission to for a DCC representative to seek medical assistance in case of an accident/emergency. I understand DCC will not be held liable in case I meet with an accident/emergency.

I understand, if medical assistance (emergency room, doctor visit, etc.) is necessary while I am attending the DCC Plus 50 program, and/or while in transit to or from the program, that I am responsible for all monetary charges for such services.