BBORR - Drivers Medical Form

Fort Stockton - Sanderson,TX

Version 7.0 2007

Driver's Medical Information Form

Must Be Completed By All Drivers

Participant:_____________________________ Social Security # (optional): __________________

Address: ______________________________________________DOB:_____________________

In the event of an accident, the following information is important. Please complete all sections.

HEALTH HISTORY

Yes	No		Yes	No		Yes	No
		Asthma			Nervous stomach			Head or spinal injuries
		Tuberculosis			Diabetes			Extensive confinement
		Kidney disease			Cardiovascular disease			Seizures, fits, convulsions, or fainting
		Psychiatric disorder			Any other nervous disorder			Permanent defect from illness/disease
		Muscular disease			Suffering from any other disease			Gastrointestinal ulcer
		Rheumatic fever

If YES to any of the above, explain:
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Participant: Sex: Height: Weight:

Date of birth: Blood type: Drug sensitivities:

Normal Abnormal Normal Abnormal

Vision: Heart condition:

Hearing: Lungs & chest:

Comments:

Drug allergies: Medical alerts:

Current medications: Other:

Name of personal Physician: Phone number:

In the event of an emergency, please contact:

Name: Phone number: Relationship:

I do ___ give Big Bend Open Road Race permission to release my medical information/physical form to emergency personnel.

I do not ___ give Big Bend Open Road Race permission to release my medical information/physical form to emergency personnel.

I certify that the above is true and complete and further certify that there is no reason physically or mentally that would preclude me from participating and driving in the Big Bend Open Road Race.

_________________________________________ ______________________________________
Participant signature Date

This form must be filled out by the primary Driver and/or 2nd Driver.

BBORR use only: Car # _______ Valid from _______________ through _______________.

Participant:		Sex:	Height:	Weight:
Date of birth:		Blood type:		Drug sensitivities:
	Normal	Abnormal		Normal	Abnormal
Vision:			Heart condition:
Hearing:			Lungs & chest:
Comments:
Drug allergies:			Medical alerts:
Current medications:			Other:
Name of personal Physician:			Phone number:
In the event of an emergency, please contact:
Name:		Phone number:		Relationship: