ࡱ> } ubjbjVV 8<<V7t t +++???8wt?48!-!-!/a5a5a57777777$9t<7+a5!5!5@a5a57-!/7666a5X-!R/76a5766 "6-! nOˏ?5X6780486B=6B=66B=+S7La5a56a5a5a5a5a5776a5a5a548a5a5a5a5B=a5a5a5a5a5a5a5a5a5t }:  Letchworth Garden City RFC want to ensure the privacy of all players, parents and carars under the data protection act within this document. All meterial provided is for informational purpose only and for the sole purpose of providing a tool for you to provide contact and medical details should an emergency arise whilst training or playing. No information is stored, shared or used for sale. The information provided would only be used in the event of an emergency to consult with Doctor or a qualified health profesional. Letchwoth Garden City Rugby Football Club Top of Form e Medical Record ID Wallet Card Generator Please complete all details below Enter Childs Information First Name: Int. Last Name: Date Of Birth:  HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1  mm/dd/yyyy Street Address City  HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1  County Post code  HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1  Phone 1 Phone 2 e-mail address Blood Type  HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1  Doctors Information First Name Surgery Phone Number  HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1  Doctor 2 Name Local Hospital to Home Phone Number  HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1  First Emergency Contacts First Name Last Name Home Phone Number  HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1  Relationship 2 Mobile Number  HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1  e-mail address Any other Info 3 Blackberry Number  HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1   Second Emergency Contacts First Name Last Name Home Phone Number  HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1  Relationship 2 Mobile Number  HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1  e-mail address Any other Info 3 Blackberry Number  HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1   Existing Medical Conditions Medical Conditions/Medical Devices (e.g. Asthma, Diabetic, etc...) List Primary Conditions/History 1.  HTMLCONTROL Forms.HTML:Text.1  2.  HTMLCONTROL Forms.HTML:Text.1  3.  HTMLCONTROL Forms.HTML:Text.1  4.  HTMLCONTROL Forms.HTML:Text.1  5.  HTMLCONTROL Forms.HTML:Text.1  6.  HTMLCONTROL Forms.HTML:Text.1  List Medications/Supplements (e.g.Ventolin1X Day, etc.) Drug Name Dosage Frequency  HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1  Drug Name Dosage Frequency  HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1  Drug Name Dosage Frequency  HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1  Drug Name Dosage Frequency  HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1   HTMLCONTROL Forms.HTML:Text.1  Drug Name Dosage Frequency Allergies / Other Info. Medications / Anything to which you are allergic Allergies (e.g. Penicillin, Bee Stings )Any Other Info 1.  HTMLCONTROL Forms.HTML:Text.1  2.  HTMLCONTROL Forms.HTML:Text.1  3.  HTMLCONTROL Forms.HTML:Text.1  4.  HTMLCONTROL Forms.HTML:Text.1  5.  HTMLCONTROL Forms.HTML:Text.1  6.  HTMLCONTROL Forms.HTML:Text.1   Information entered here will NOT be stored for any purpose or will be given away or used in any manner.      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