Middlehaven Inc. Medical Information Form

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Middlehaven Inc.(Hereafter referred to as Middlehaven or Middlehaven LARP) Medical Information Form

Player's Last Name: *

Player's First Name: *

Player's Age: *

Player's Phone Number: *

Emergency Contact Name: *

Emergency Contact Phone Number: *

Do you have a history of any of the following? *

(Check all that apply)

Hypertension

Seizures

COPD

Stroke

Diabetes

Cardiac

Asthma

Allergic Reaction/Anaphylaxis

None

Required

Have you been prescribed an Epi-Pen, rescue inhaler for asthma, or any other prescription item or medication for use in an emergency? *

*Note: If you have been prescribed any of these, you are REQUIRED to have the prescription on your person during the event.

Yes

Required

Do you have any other serious medical issues or been under a physician’s care recently? *

Yes

Required

Please list any medical issues that may affect your ability to participate:

Have you been fully vaccinated against Covid-19 *

Note: Middlehaven reserves the right to require proof of vaccination.

Yes

Required

Optional: You may consent below to Middlehaven adding your name to a list of fully vaccinated players. Agreeing will allow you to show your proof of vaccination once for the season at the next event, and not having to show proof for the remainder of the season. Agreement is optional and will not affect your ability to attend. *

Note: Middlehaven reserves the right to modify, change or remove vaccination requirements. Changes in vaccination policy for attendees may require proof of vaccination be shown again.

Yes. I would like my name added to the vaccinated player list. I understand if vaccination requirements change, i may be required to show proof of compliance with new requirements.

No. I prefer to show my proof of vaccination each event.

Required

Please note: If you have a medical condition which renders you unsafe to play, you should not participate in the game.

Agreement:

To the best of my knowledge, the information given above is correct. In case of a medical emergency, I understand and agree that I may be evaluated or treated by Middlehaven Inc staff or players acting in good faith as Good Samaritans. I further understand and agree that I may be evaluated, treated, or transported by an ambulance or emergency services should I not be able to give consent.

I understand that Middlehaven Inc Events are considered invitation only events. I understand that Middlehaven Inc Staff, as assigned by the Board of Directors, may limit, modify or suspend my attendance and/or participation in events.

I hereby give permission to the Middlehaven Inc Staff, players, or representatives to evaluate, treat, or transport me to the hospital or medical/dental office if needed. I further grant Middlehaven Staff, players, or representatives the right to share, copy or otherwise deliver this form or the information contained in it to emergency services, medical personnel, or hospital(s) in the course of providing for my care.

I hold harmless all Middlehaven Inc staff, representatives, and players in the event of a medical emergency.

By completing this form, I signify my agreement to the above. *

I agree.

Required

By entering my name, I digitally sign this document. *

(Please type your full name)

Submit

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