HYCAT Handbook: Medical Information

EMERGENCY MEDICAL AND SURGICAL PERMIT
UC AQUATIC TEAM

[REVISED 08/15/2000]

THIS FORM  MUST  BE COMPLETED AND RETURNED TO THE UC AQUATIC TEAM {HYCAT} SWIMMING
OFFICE PRIOR TO THE SWIMMER BEING PERMITTED TO TRAVEL TO AN AWAY SWIM MEET (OR
OTHER HYCAT RELATED ACTIVITY/FUNCTION) WITHOUT THEIR PARENTS ACCOMPANY THEM.

SWIMMER'S NAME: ___________________________________________________   AGE: _____
HOME ADDRESS:   ________________________________________________________________
                          street               city               state    zip
DATE OF BIRTH:  ___/___/___   RELIGIOUS PREFERENCE:_____________________________
MALE: _____   FEMALE: _____   BLOOD TYPE {IF KNOWN}: ___________________________
NEAREST RELATIVE: ___________________________________   RELATIONSHIP: __________
HOME ADDRESS:     ______________________________________________________________
                          street               city               state    zip
BUSINESS ADDRESS: ______________________________________________________________
                          street               city               state    zip
{HOME} PHONE NO: (____)______________   {OFFICE} PHONE NO: (_____) _____________
FATHER'S/GUARDIAN'S OCCUPATION: ________________________________________________
EMPLOYED BY: ___________________________________________________________________
HOSPITALIZATION INSURANCE {NAME OF COMPANY}: ___________________________________
POLICY NO: ________________   MEDICAL {YES / NO}  ______________________________
                              SURGICAL {YES / NO} ______________________________
                              ACCIDENT {YES / NO} ______________________________
FAMILY DOCTOR'S NAME: ____________________________   PHONE NO: (____)___________
SPECIAL MEDICATION{S}: _________________________________________________________
________________________________________________________________________________
[NOTE: if you need more space, please utilize the back side of this page]

ALLERGIE{S}: __________________________________________________________________
________________________________________________________________________________
[NOTE: if you need more space, please utilize the back side of this page]

I GIVE MY PERMISSION FOR A QUALIFIED PHYSICIAN TO PERFORM ANY MEDICAL OR 
SURGICAL PROCEDURE HE/SHE DEEMS ADVISABLE FOR THE WELFARE OF THIS APPLICANT 
WHILE HE/SHE IS PARTICIPATING, OR TRAVELING, WITH THE HYCAT SWIMMING PROGRAM.

FURTHER, THIS AUTHORIZATION PERMITS SAID PHYSICIAN TO HOSPITALIZE; TO SECURE ANY
APPROPRIATE CONSULTATION; TO ORDER INJECTIONS, ANESTHESIA (LOCAL, GENERAL OR 
BOTH), OR SURGICAL PROCEDURES FOR THIS APPLICANT.

THE UNDERSIGNED DOES HEREBY ASSUME AND AGREE TO PAY ANY INDEBTEDNESS, OR 
PHYSICIAN'S AND SURGEON'S FEES AND ALL APPROPRIATE HOSPITAL FEES FOR SUCH SER-
VICES.

DATE: ____________________  SIGNATURE: _________________________________________

RELATIONSHIP TO SWIMMER: _______________________________________________________

ADDITIONAL INFORMATION:  _______________________________________________________
________________________________________________________________________________
________________________________________________________________________________


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        NAME: _______________________________________________________________
                        LAST                    FIRST               MIDDLE

        DATE OF BIRTH: __________________   AGE: __________   SEX: __________

        ADDRESS: ____________________________________________________________
                     STREET             CITY            STATE           ZIP

        TELEPHONE [HOME] (____) _____-________  [OTHER] (____) _____-________
       
        EMERGENCY CONTACT: __________________________________________________

                  ADDRESS: __________________________________________________

                TELEPHONE: (_____) _____-______ [H]  (_____) _____-______ [B]

        PLEASE CIRCLE EITHER "YES" OR "NO" AND PROVIDE ADDITIONAL DETAILS 
        WHERE REQUESTED ON ALL SIDES OF THIS FORM.  ALL INFORMATION WILL 
        REMAIN CONFIDENTIAL.

        ( 1) Are you allergic to any medication (aspirin, penicillin, sulfa, 
             etc.)?
             NO   YES (list) ________________________________________________

        ( 2) Do you take any prescribed medication on a permanent, or semi-
             permanent basis (steroids, birth control pills, antibiotics,
             anti-inflammatory, etc.)?
             NO   YES (list) (a)_____________________________________________
                             (b)_____________________________________________
                             (c)_____________________________________________

        ( 3) Do you have a seizure disorder (epilespy)?  NO   YES  If yes, 
             give date of last seizure: _____________________________________

        ( 4) Have you ever been told by a physican you have epilepsy?
             NO   YES  If yes, what medication? _____________________________
             ________________________________________________________________

        ( 5) Have you ever been treated for diabetes?   NO   YES  If yes, 
             are you on what medications? NO   YES  If yes, what medication: 
             ________________________________________________________________ 
             ________________________________________________________________

        ( 6) Have you ever been told by a physicion you were anemic? NO   YES
             If yes, when: _____________________

        ( 7) Have you ever been told by a physician you have sickle cell 
             anemia?  NO   YES

        ( 8) Have you ever been told by a physician you have sickle cell 
             trait?  NO   YES

        ( 9) Do you have high blood pressure (hypertension)?   NO   YES  If
             yes, are you on medication?  NO   YES  If yes, what medication? 
             ________________________________________________________________

        (10) Do you have, or have you ever had, the following diseases?  If 
             yes, give detail(s).

             NO   YES   Heart Disease (heart murmur,    _____________________
                        rheumatic fever)                _____________________

             NO   YES   Lung Disease (pneumonia)        _____________________
                                                        _____________________

             NO   YES   Kidney Disease (infections)     _____________________
                                                        _____________________

             NO   YES   Liver Disease (mononucleosis,   _____________________
                        hepatitis, etc)                 _____________________
        
        (11) Have you ever been told by a physician you have asthma?  NO  YES  
             If yes, are you on medication?  NO   YES   If yes, what medica-
             tion? __________________________________________________________

        (12) Have you ever had a hernia?  NO   YES   If yes, has it been 
             repaired?  NO   YES  Date repaired? ____________________________

        (13) Have you ever been "knocked-out" (unconscious)  NO   YES  If 
             yes, give date(s): _____________________________________________

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http://members.citynet.net/HYCAT -- Revised: 31 December 2002
golson@uchaswv.edu
Questions or Comments
Copyright © 2003