Fillable U.S. DEPARTMENT OF ENERGY 2020 Regional Science Bowl (Ames Laboratory)

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U.S. DEPARTMENT OF ENERGY 2020 Regional Science Bowl (Ames Laboratory)

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  • 10 check-boxes
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File type: PDF

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Name ________________________________ Page 1 of 3
U.S. DEPARTMENT OF ENERGY
2020 Regional Science Bowl - Ames, Iowa and National Science Bowl
®
Coach Confidential Medical Information and Emergency Notification Form
(Please fill out the entire 4-page form)
This is a PDF Form filler document. Click on the space and type in the information requested. Once
the form is complete: (1) click “File,” then “Save As” and give it a name and save it on your computer;
(2) print the completed form; (3) please sign the form in blue ink.
School Name:
Name Birth Date
Gender: M
F
Street Address
City State Zip Code
Home Telephone ( )
PLEASE LIST TWO EMERGENCY CONTACTS:
Primary Contact
Contact #2
Name:
Name:
Phone:
Phone:
Cell Phone:
Cell Phone:
Relationship:
Relationship:
Allergies
Yes No If Yes, specify:
Medication
Food
Environmental
Medical History (To include surgeries)
Date of Last Tetanus Shot:
(A) Current/Recent Medical History/surgery (within the past 12 months)
Name ________________________________ Page 2 of 3
(B) Previous Medical History/surgery (please include ALL medical history beyond 12 months)
Medication Information (Prescribed and Over-the-Counter Medications and Purpose)
Please follow the format listed below.
Current Prescribed Medications – PLEASE PRINT!
Medication/Dosage
Purpose/Used For
(Example: Albuterol/10mg per day)
(Example: Asthma)
Current Over the Counter Medications – PLEASE PRINT!
Medication
Purpose/Used For
(Example: Advil/as needed)
(Example: Headaches)
Physical Limitations/Needs (Please include any assistive devices that need to be provided):
Mobility Limitations
Visual Limitations
Communications Limitations
Name ________________________________ Page 3 of 3
Dietary Restrictions (vegetarian, kosher, etc.):
If you have severe dietary restrictions, please list samples of meals that you CAN eat:
Religious or Cultural concerns that may affect care: (e.g. No Blood Transfusions)
PHYSICIAN & HEALTH INSURANCE
Physician’s Name: Phone Number:
Do you have Health Insurance? YES _____ NO _____
If Yes, complete the following:
Insurance Company:
Policy Number: Phone Number:
CONSENT TO MEDICAL CARE AND TREATMENT
I hereby authorize and consent to the administration of all medical and/or surgical treatment(s)
by a licensed physician, nurse or hospital in the event I am not available to consult with the
attending physician(s), and the attending physician(s) deems it advisable to proceed with such
treatment(s).
(Print Name)
Date
Signature in Ink or Adobe Entrust
For National Science Bowl® Regional Competition Use - Please upload the
completed form to the team's registration page:
https://apps.orau.gov/nsb-coach/Account
OFFICIAL USE ONLY
May be exempt from public release under the Freedom of Information Act (5 U.S.C. 552), exemption number and category: 6, Personal Privacy
Department of Energy Review required before public release
Name/Org: Allen Wash/ORISE Date: 9/12/2019 Guidance (if applicable): CG-SS-5
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U.S. DEPARTMENT OF ENERGY 2020 Regional Science Bowl (Ames Laboratory)

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Completed 19 July 2020

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