Emergency Information & Medical History

Per the MA Department of Public Health, 105 CMR 430.151B, all staff personnel must provide the following information.
If you are 18 years of age or older, you may complete this form with your signature. If you are under 18 years of age,
you must have this form signed by a parent or guardian, or by a licensed health care provider.

Name

First Name

Last Name

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you have any allergies?

Please include both food & medicine allergies, along with the severity.

Please list all required medications

In the event of a medical emergency, this is pertinent information for appropriate medical treatment.

Will you be bringing any medications to PUDDLESTOMPERS programs?

Yes

If yes, please state which medications:

Do you have any health conditions or impairments which may affect your activities while attending PUDDLESTOMPERS programs?

Tuberculosis Acknowledgement

I acknowledge that I am not suffering from tuberculosis in a communicable form or have any evidence of symptoms thereof.

I agree

I do not agree

Emergency Contact

First Name

Last Name

Relationship

Emergency Contact Number

Electronic Signature

I hereby declare that the details above are true and correct to the best of my knowledge and that I am responsible for informing the Director of Operations of any changes therein, immediately. Please note that an esignature is the electronic equivalent of a hand-written signature. Please enter your full name below. If you are under 18 years of age, a parent, guardian, or licensed health care provider must sign below. If you are submitting a parent or guardian's signature, please also include the relationship to the participant in the field below.