THON 2013 Dancer Registration Packet

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DANCER REGISTRATION PACKET 2013 Penn State IFC/Panhellenic Dance Marathon Medication for THON Weekend Name of Medication: ______________________________________________________________ Medicine Dose: __________________________________________________________________ How many times will you take this medication on Friday? Saturday? Sunday? Friday: __________ Saturday: __________ Sunday: __________ Special Needs: ___________________________________________________________________ Name of Medication: ______________________________________________________________ Medicine Dose: __________________________________________________________________ How many times will you take this medication on Friday? Saturday? Sunday? Friday: __________ Saturday: __________ Sunday: __________ Special Needs: ___________________________________________________________________ Name of Medication: ______________________________________________________________ Medicine Dose: __________________________________________________________________ How many times will you take this medication on Friday? Saturday? Sunday? Friday: __________ Saturday: __________ Sunday: __________ Special Needs: ___________________________________________________________________ Name of Medication: _____________________________________________________________ Medicine Dose: __________________________________________________________________ How many times will you take this medication on Friday? Saturday? Sunday? Friday: __________ Saturday: __________ Sunday: __________ Special Needs: __________________________________________________________________ 18
DANCER REGISTRATION PACKET 2013 Penn State IFC/Panhellenic Dance Marathon Dancer Medical History Form Dancer B 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: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 19
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