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HERITAGE HIGHLANDS HIKING CLUB

Medical Alert Form

Please complete the following information and keep in your pack on all Heritage Highlands sponsored hikes:

NAME:	BIRTHDAY:
STREET ADDRESS:	PHONE:
INSURANCE CO:	POLICY NO:
PHYSICIAN:	DR’s. PHONE:

Please place your initials in the space provided for all conditions which apply.

	HEART CONDITION		ASTHMA
	BREATHING PROBLEMS		DIABETIC
	SEIZURES		HIGH BLOOD PRESSURE
	EMOTIONAL PROBLEMS		HARD OF HEARING
	ALLERGY TO BEES, WASPS, ETC
	ALLERGIES TO OTHER INSECTS (PLEASE LIST):
	ALLERGIES TO ANY MEDICATIONS (PLEASE LIST):
	OTHER MEDICAL CONCERNS:

For all items initialed above, please indicate any specific treatment or medications to be (or not to be) administered in case of emergency: ____________________________________________

IN CASE OF EMERGENCY, PLEASE NOTIFY:

NAME: ___________________________________________________________________

RELATION: _______________________ PHONE NUMBER: _________________________

I HEREBY AUTHORIZE _______ DO NOT AUTHORIZE ________ ANY BASIC FIRST AIDE PROCEDURES TO BE TAKEN IF IT IS DEEMED NECESSARY.

SIGNATURE: ________________________________________ DATE: _________________