The Nicholas Center's Emergency Contact, Medical & Waiver Forms

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This form must be filled out by all participants and updated annually or as needed.

Today's Date *

YYYY

Name of Participant *

Date of Birth *

YYYY

Participant's Full Residential Street Address , City , State and Zipcode *

Diagnosis(es) *

List any allergies. If none, note N/A *

Physical restrictions or limitations. If none, note N/A *

List any Medications, dosages and what they are used to monitor/control, If none, note N/A *

List all Doctors,affiliations and numbers to be called in an emergency *

Primary Caregiver 1 : First and Last Name *

Primary Caregiver 1: Email *

Primary Caregiver 1: Home Address *

Primary Caregiver 1: Home Phone Number *

Primary Caregiver 1: Cell Number *

Primary Caregiver 1: Work Number *

Secondary Caregiver 2: First and Last Name *

Secondary Caregiver 2: Email *

Secondary Caregiver 2: Home Address *

Secondary Caregiver 2: Home Phone *

Secondary Caregiver 2: Cell Phone *

Secondary Caregiver 2: Work Phone *

Additional Emergency Contact Name *

Emergency Contact relation to participant *

Emergency Contact Number *

Photo and Video Release: Must Check one *

Yes, Nicholas Center may use photos and videos of the participant,for promotional Print, Press, Radio and Social Media Outlets

No, please do not use photos or videos of the participant in any capacity.

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