Blair Wallis Trail Ride Participant Health Form

__________________________________________________________________________________________

The purpose of this form is to provide the Blair Wallis Trail Ride management with your health information in the event of a medical emergency. Please complete a separate form for each rider. Make copies of the form as needed for multiple riders in your party. Your health information is confidential.

 

Name:________________________________________________________  Age:___________________

                 (Last, First)                                                                                                                                                                     (If under 18)

Address:______________________________________________________________________________

City:________________________________  State:__________________________  Zip:_____________

Telephone:____________________  ____________________  E-mail:_______________________________

                                  (Day)                                                          (Evening)

Signature of legal guardian, if participant is under 18 years of age.

Guardian name:________________________________________________________________________

Guardian signature:_____________________________________________________________________

Telephone:____________________  ____________________

                                  (Day)                                                          (Evening)

 

In case of emergency, please contact _____________________ at telephone number __________________.

 

Do you smoke? 
 Yes
 No

Are you taking any medication? 
  Yes 
  No

                 If yes, what is the name of the medication(s)?

                 1.__________________________________________________________________

                 2.__________________________________________________________________

                 3.__________________________________________________________________

Do you have any allergies? 
  Yes 
  No

                 If yes, please list your allergies.

                 1.__________________________________________________________________

                 2.__________________________________________________________________

                 3.__________________________________________________________________

Are you diabetic? 
  Yes 
  No

                 If yes, do you depend on insulin? 
  Yes 
  No

Do you suffer from:

  Arthritis            
  Asthma             
  Rheumatism    
  Emphysema

  Tendonitis        
  Chronic            
  Bronchitis                         
  Other _________________________________

Do you have high blood pressure? 
  Yes 
  No

Have you ever had surgery? 
  Yes 
  No

                 If yes, what type of surgery?________________________________ And when?__________________

Are you pregnant, or is there a possibility that you might be pregnant? 
  Yes 
  No

                 If yes, when is your due date?___________________________________________

Trail Ride Release

Health Form

Registration Form

Rules

Description / Directions / Schedule

State Statute– Equine Activities