RUN GROUP: ___________                                                         CAR NO. ___________

OHIO VALLEY REGION

PORSCHE CLUB OF AMERICA

MEDICAL INFORMATION FORM

Please complete this form and turn it in when you register, either at the motel or at the track.

Hopefully, we will not have to use this information, but we would appreciate having it available to assist the medical personnel if required. Run group and car number will be filled out by the Registrar.

Thank you for your cooperation.

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Name: _____________________________________________________

Blood Type: ________

Allergies: ________________________________________________________________

Current Medications:________________________________________________________

_________________________________________________________________________

CHECK ANY OF THE FOLLOWING THAT ARE PERTINENT:

Contact Lenses _________                              Dentures _________

Asthmatic _________                                      Diabetic __________

Epileptic _________

List any special medical conditions: ____________________________________________

_________________________________________________________________________

In case of emergency notify: ______________________________

Phone# ______________________________                Is this person at the track? ______

Family Doctor: _____________________________       Phone#   ____________________

Medical.doc 12/22/05