VITAL INFORMATION

NAME: ____________________________________PHONE: ___________________________________

ADDRESS: _________________________________ BIRTH DATE: ______________________________

CITY/STATE/ZIP______________________________________________

EMERGENCY CONTACT: ____________________PHONE # __________________________________

MEDICAL INFORMATION

HEALTH HISTORY

check if you have had any of the following:

__eyesight impairment __mental or emotional disorder
__hearing impairment __disease of the ears
__speech impairment __arthritis
__disorders of nervous system __diabetes
__sinusitis __tuberculosis
__disease of the kidneys __hernia
__heart disease __hay fever or asthma
__rheumatic fever __intestinal disorders
__abnormal blood pressure __other serious allergies

other major illnesses: ________________________________________________________________________

MEDICAL HISTORY

Have you been hospitalized or had a serious illness in the last year? ___YES ___NO

If YES, do you feel this would restrict your participation in this event? ___YES ___NO

Is there anything about your present health that an emergency physician should know about and/or details of checked items above?

 

 

Approximate Date of Last Tetanus Shot: ______________________

List any prescription drugs you take regularly and reason: __________________________________________________

Any drug allergies: ___YES ___NO

If yes, please list:

 

Any food allergies: ___YES ___NO

If yes, please list:

 

 

Doctor's Name ___________________________________ Office phone _____________________
EM Phone ___________________

CONSENT TO TREATMENT

If I should meet with serious accident or illness, and a family member cannot be reached, I authorized:

_____ treatment by available physician _____ other (list below)

 

SIGNED _______________________________________________DATE ___________________

 

DAGORHIR

RAGNAROK XIII

PARTICIPANT WAIVER of LIABILITY

I, the undersigned do hereby acknowledge that I am willfully participating as a combatant in a full contact sport, at my own risk, within Dagorhir, Ragnarok XIII according to my own recognizance; thus relieving Dagorhir, Ragnarok XIII and its members from all liability concerning personal injuries sustained, accidental or otherwise, at sanctioned events sponsored by Dagorhir, Ragnarok XIII. I understand the risks of participating and I do so at my own personal risk. I agree to follow all rules, both governmental and those of Dagorhir, Ragnarok XIII. I understand that the activities of Dagorhir, Ragnarok XIII, by their nature, are potentially dangerous. I understand that I can and may get myself injured. I understand that the activities of Dagorhir, Ragnarok XIII, Dagorhir, and their affiliations are potentially dangerous and I participate of my own free will. I agree that my actions are my personal responsibility. I waive the right to liability versus Dagorhir, Ragnarok XIII, any and all members of Dagorhir, Ragnarok XIII, property owners where Dagorhir, Ragnarok XIII meets, and any and all affiliates of Dagorhir, Ragnarok XIII. I agree to follow the laws of Dagorhir, Ragnarok XIII as brought forth in the constitutions, bylaws and the rulings of Dagorhir, Dagorhir, Ragnarok XIII, and their affiliations. I agree not to initiate any activity that would damage Dagorhir, Ragnarok XIII, Dagorhir Battlegames, Inc., any of their affiliations, or any of their members.

Because Dagorhir Battlegames is considered a physical and full contact sport, it is recommended that all combatants wear protective equipment. This equipment includes, but is not limited to: gloves, elbow pads, kneepads, kidney (weight) belt, cups or jockstraps for men and sports bras for women. Failure to wear protective equipment may lead to injury during events.

SIGNED ____________________________________________ DATE ___________________

WITNESS ___________________________________________ DATE ___________________

 

PARENTAL CONSENT OF PARTICIPATION

Any person under eighteen (18) years of age must have the consent of a legal guardian or parent to participate in Ragnarok XIII. This document must also be notarized by a notary, with seal and signature below to be valid.

I, the undersigned, understand the activities of Dagorhir, Ragnarok XIII, and the risks involved. I have read the above waiver and agree to allow my child to participate in activities sponsored by Dagorhir, Ragnarok XIII. I understand and agree that this document is legally binding to both myself and my child.

PARENT SIGNATURE _________________________________DATE ___________________

CHILD SIGNATURE ___________________________________DATE ___________________

WITNESS ____________________________________________DATE ___________________

NOTARY SIGNATURE _________________________________DATE___________________