Health Intake Form for Wolvenwold 2010

(Please include this form with your registration if there are medical issues that you believe we need to be aware of.  We thank you for your cooperation, this helps us keep us all safe and sound!)

Name:

Age:

Allergies:

Health Issues (in detail):

Do you have your medication(s) with you?

What medications are you taking?

Do you have a doctor, or an emergency contact that we can use for you (list all)?  Is there someone here who we should find if there is a problem?

Thank you for your cooperation, this will help us keep you safe and sound!

Signed__________________________________________

Date________________________________________________