Driver Medical Form
(Must be Completed)
Driver's Name:                                                                                               

Date of birth:                                     Blood Type:                          

Date of last tetnus booster:                                                                      

Personal Physician:                                                                               

Physician's Address:                                                                                    

                                                                         Phone:                                   

Special Conditions (Diabetes, Hemophilia etc.)                                        

                                                                                                                 

Current Medications:                                                                                    

                                                                                                                        

Drug Allergies:                                                                                                

                                                                                                                          I hereby certify that I have no known physical or mental impairments
that may jeopardize myself or others by my   participation in this event.

Driver Signature:                                                            Date                  

***************************************************************** This form is for medical purposes only.  All information on this sheet shall remain confidential.