MAY

Medical Release Form

Swimmers Name: ___________________________________ Birthdate_______________ Gender_______ Age_____

Address:________________________________________________________________________________________________________________________________________ Phone:____________________________________Home:_________________________

Parent or Guardian:__________________________________ Phone:____________________________________Work:_________________________

Address:________________________________________________________________________________________________________________________________________

Emergency Contact:_______________________________________________________

Relationship to Swimmer:__________________________________________________

Phone: __________________________

Allergies

Does swimmer have any allergies to Medications?(penicillin,sulfa, aspirin, etc.)

___ No

___ Yes-Please List

____________________________________________ ____________________________________________

Does swimmer have any other allergies?

___ No

___ Yes-Please List

____________________________________________ ____________________________________________

Medical History

___Asthma ___High Blood Pressure ___Liver Condition

___Heart Condition ___Anemia ___Hernia

___Diabetes ___Lung Condition ___Swimmer’s Ear/Ear Infections

___Epilepsy/Seizures ___Kidney Condition ___Headaches/Sinus

___Other-Please Explain

Date of last Tetanus Booster:_______________________________

Please list any current or regular medications: ________________________________________________________________________________________________________________________________________________

Does swimmer have history of any injuries or surgeries that could affect or be affected by swimming?

___Shoulder ___Back ___Head Injury

___Neck ___Knee

___Other- Please Explain ________________________________________________________________________________________________________________________________________________

Is swimmer currently undergoing physical therapy for an injury?

___No

___Yes- Please Explain

________________________________________________________________________________________________________________________________________________

Does swimmer wear any of the following?

___Glasses ___Braces

___Contacts ___Retainer

Insurance:______________ Doctor:________________ Phone: ___________________

I,_____________________________________ give my permission for the MAY coaching staff to treat my child, __________________________________ in the event of an emergency. I do not hold the Madison Area YMCA or MAY Swim Team responsible for any medical cost incurred from a medical emergency.

_____________________________________

Signature of parent or legal guardian