Family Outfitters of
Coshocton, Ohio
|
Each person in each hunting group must fully complete the following emergency medical
form. This form is mandatory.
Please send completed form to 18155 Township Road 65, Coshocton, Ohio 43812 with
non-refundable deposit.
Emergency Medical Form
In the event of an emergency, who should be contacted? Include name, relationship (i.e.
spouse, brother...), and phone number(s) of at least 2 persons:
Name Relationship Phone Number
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Date of your last tetanus shot (if you are not sure, write unknown):
_____________________________________________________________________
Please provide any information regarding your medical history of which a physician or
hunting guide should be alerted: (allergies, medications being taken, physical impairment):
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Consent to Receive Medical Treatment in the event of an emergency:
If you give consent to receive medical treatment in case of an emergency, please sign and
date.
Signature______________________________________________
Date__________________________________________________
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