Participant’s Medical Information Form – Gabriola Recreation Society

A participant’s personal and medical information form is required for our records. You only have to do this ONCE for each participant. When registering for future events you can simply check a box stating we have your information on file. Please fill out the fields below and hit submit.

You do not need to fill in this form if you have already submitted this information to us more recently than August 2017.

If you are unable to fill out the online form, it is available to download and print. Please fill it in and submit in-person. The information provided will then be transferred to our database. Forms here: Adult Form (19 years+) and the Child/Teen Form (18 and under).

Participants Information
Participants Name*
First Last
Date of Birth*
Participants Age Type
- Child (Ages 6-12)
- Teen (Ages 13-18)
- Adult (Ages 19+)
- Senior (Ages 60+)
Address
Street Address City Province Postal Code
Email*
Phone
Do you give permission to the Gabriola Recreation Society (GRS) to use photographs and/or videos of the participant you are registering in print form?*
- Yes
- No
Do you give permission to the Gabriola Recreation Society (GRS) to use photographs and/or videos of the participant you are registering on the GRS website, e-newsletter, and/or social platforms?*
- Yes
- No
Medical Information
Family Doctor (if applicable)
Family Doctor Phone or Clinic Phone
Emergency Contact #1 (Parent / Guardian)*
First Last
Emergency Contact #1 - Home Phone*
Emergency Contact #1 - Work Phone
Emergency Contact #1*
First Last
Emergency Contact #1 - Home Phone*
Emergency Contact #1 - Work Phone
Emergency Contact #2*
First Last
Emergency Contact #2 - Home Phone*
Emergency Contact #2 - Work Phone
Identify any allergies,medical conditions,medications or disabilities the instructor should be aware of. Please be aware that Instructors WILL NOT ADMINISTER MEDICATIONS. This information is confidential and will only be used in the case of an emergency.
None
Parent / Guardian Signature
Participants Signature
Comments
This field is for validation purposes and should be left unchanged.

Participants Information

Medical Information