LUBBOCK AREA GROTTO PERSONAL MEDICAL INFORMATION
AND
CONSENT FOR TREATMENT NAME:_______________________________________________________________

ADDRESS:____________________________________________________________

HOME PHONE: (____) ____ _______             WORK PHONE: (____) ____ _______

Name of two persons who may be contacted in an emergency:
     1) NAME: ____________________________________ Ph # (____) ____ ______
     2) NAME: ____________________________________ Ph # (____) ____ ______

Date of last Tetanus Inoculation: ___________________
List any allergies and/or describe medications needed: ________________________
     _________________________________________________________________

Do you have any medical problems which would require special treatment in the event you were unconscious? ( )Yes ( )No   If Yes, describe: _________________________
     ________________________________________________________________

Any history of adverse reactions to bee, wasp, or other insect bites? ( )Yes ( )No
     If Yes, describe:____________________________________________________

Do you carry medications on your person? ( )Yes ( )No
Comment on any medical condition that attending doctor or medical emergency crew should need to know to effectively treat you: ______________________________
     ________________________________________________________________
     ________________________________________________________________

I _____________________, hereby authorize, consent, and give my permission for the obtaining and application of such medical and/or surgical treatment as may be deemed prudent and necessary to insure my safety. It is agreed and understood that I do hold all persons associated with LUBBOCK AREA GROTTO, SOUTHWESTERN REGION, and NATIONAL SPELEOLOGICAL SOCIETY harmless from any and all consequences arising out of such treatment provided that these medical services are sought and obtained with ordinary and reasonable care relative to the circumstances. I hereby request that in the event of illness or accident, measures be instituted without delay as judgement of medical personnel dictates. Signed on this ______ DAY of ______________, 20___

Signature: ____________________________________

Printed name: _________________________________