Medical Card

Everyone participating in the event must comeplete a USERA Medical Card.

Your Name:	Date of Birth:	Gender: Male Female
Your E-mail Address:	Reenter Your E-mail Address:
Address Line 1:	Address Line 2:
City:	State:	Zipcode:
Home Phone Number:	Work Phone Number:	Cell Phone Number:
Current Medications:	Height:	Weight:
Medical Conditions:	Eye Color:	Hair Color:
Allergies:	Date of Tetnus Booster:	Blood Type:
Name of Doctor:	Doctor's Phone Number:
Name of Next of Kin:	Next of Kin's Phone Number:
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SPEC RACER FORUM

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DANVILLE, VA 24541
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