Wycombe Wanderers Foundation - Walking Football Participant Medical Form (Tuesday - Male)

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* 1. Participant Name

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* 2. Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

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* 3. DOB

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* 4. Telephone Number

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* 5. Emergency Contact 1 Name/Telephone Number + Relationship to Participant

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* 6. Emergency Contact 2 Name/Telephone Number + Relationship to Participant

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* 7. Does the participant have any pre-existing medical conditions?

Yes

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* 8. If yes, please provide details

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* 9. Is the participant affected by any of the following conditions?

Musculoskeletal condition

Abnormal blood pressure

Cardio-vascular condition

Respiratory condition

Joint surgery

Neurological condition

Epilepsy

Skin condition

Asthma

Anaphylaxis

Diabetes

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* 10. If you have answered "yes" to anything in question 9 or if you feel there are any other medical conditions we need to be aware of, please give further details

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* 11. Please make us aware of any recent injuries

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* 12. Are there any particular exercises the participant should avoid or any exercise that would be particularly beneficial?

Yes

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* 13. If yes, please give details

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* 14. Does the participant suffer from any allergies?

Yes

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* 15. If yes, please give details

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* 16. Is the participant currently taking any medication?

Yes

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* 17. If yes, please list here

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* 18. Is there any other relevant information that may affect any treatment in an emergency?

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* 19. Doctors Name

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* 20. Doctors Telephone Number

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* 21. DECLARATION - All the information I have provided is correct to the best of my knowledge

Signed -

Date -