KERR COUNTY FAIR ASSOCIATION, INC.

EVENT PARTICIPATION

MEDICAL INFORMATION SHEET

Please complete this form and return with application. This includes the Notary on the second page of this form. We need this information in case there are any accidents and there is no parent available to seek medical attention.

NAME:
PHONE: Home			Work
ADDRESS:
CITY	STATE				ZIP
MAILING ADDRESS:
AGE: BIRTH: (m)		(d)		(y)

MOTHER'S NAME:
MOTHER'S ADDRESS:
PHONE: Work	Home

FATHER'S NAME:
FATHER'S ADDRESS:
PHONE: Work	Home

FAMILY DOCTOR:

PHONE:

IN CASE OF EMERGENCY CONTACT:
PHONE:	RELATIONSHIP:

DATE OF LAST TETANUS SHOT: ________________________________________

LIST ANY ALLERGIES OR MEDICAL PROBLEMS:

I GIVE MY DAUGHTER PERMISSION TO TAKE:

ASPIRIN __________ ACETAMINOPHEN __________ TYLENOL _________

TO WHOM IT MAY CONCERN:

I,	,	hereby give my permission to the bearer
of this note to seek medical help for my daughter,

I also give the physician permission to treat any medical condition that might arise.

SIGNED:		DATE:
	PARENT/GUARDIAN

Sworn to and subscribed before me this

day of

20

Notary Public in, and for

the State of Texas.

My commission expires: