THON 2013 Dancer Registration Packet

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DANCER REGISTRATION PACKET 2013 Penn State IFC/Panhellenic Dance Marathon Dancer Medical History Forms 16
DANCER REGISTRATION PACKET 2013 Penn State IFC/Panhellenic Dance Marathon Dancer Medical History Form Dancer A COUPLE # ___________ First Name: ______________________________ Last Name: ______________________________ Gender (Circle): Male Female Date of Birth: ________ / ________ / ________ Age at THON: _________ PSU ID Number: _____________________________________________________________________ Address – Local: ______________________________________________________________________ Phone – Cell: __________-__________-______________ Address – Home: _____________________________________________________________________ Phone – Home: __________-__________-______________ Medical Information (Please Check All that Apply) _____ Asthma _____ Diabetes _____ Emphysema _____ Heart Problems _____ Epilepsy _____ Wear Contacts/Glasses _____ Allergies _____ Other Medical Issues/Allergy Information. (If so please list below) Pain Medication Preference (Circle): Tylenol Ibuprofen If you checked YES to any of the above please explain: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 17
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