WHITE WATER 

LEARNING CENTER

OF GEORGIA 

      

Medical Information and Emergency Contacts
Participant, and the parent or guardian of a minor Participant, accepts full responsibility for determining Participant’s medical and physical qualification for participating in White Water Learning Center of Georgia activities. Providing the following medical information is optional and is intended to help WWLC, rescue, first aid and medical personnel take appropriate action to assist participants in WWLC activities in first aid, medical or other emergencies.
Participant’s Name _____________________________________________________ Age _____ Sex ______ 
Street  ______________________________ City ____________________  State ______ Zip  ____________
Email  ______________________________________________  Phone Number _______________________
Allergies  _______________________________________________________________________________
Medications & Dosages _____________________________________________________________________
         ___________________________________________________________________________________

Medical Conditions _________________________________________________________________________

Medical History (e.g., appendectomy) ___________________________________________________________

Disabilities _______________________________________________________________________________
Other Concerns  ___________________________________________________________________________

Personal Physician ________________________ Office (      ) _____________  Emergency (      ) ___________
Emergency Contact #1 _____________________ Daytime (      ) ___________  Cell/Pager (      ) ____________
Emergency Contact #2 _____________________ Daytime (      ) ___________  Cell/Pager (      ) ____________
Signature of  Participant  (Adult or Minor) ____________________________________  Date _______________
Signature of Parent/ Guardian (Minor Participant) _____________________________     Date _______________