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