BJJ Rotterdam emergency form

Personal information

First Name *

Last Name *

Name *

Date of birth *

Gender

Nationality *

Address *

Zipcode *

City *

My e-mail address *

My e-mail address may be used for any newsletters or other communications from BJJ Rotterdam. *

Yes

My phone number *

In case of emergency, contact: *

(e.g. name partner / parent / friend)

Emergency phone number *

Do you have any medical conditions/allergies? If yes which one. *

Are you under treatment? If so, where? *

(full name and telephone number of the attending physician)

Do you take medication? If yes which one? *

Is there anything else to keep in mind? *

(e.g. old injuries, operations or other limitations)

Blood type

Do you have a first aid certificate? *

Yes

Privacy

I give permission to store this data for the purposes of BJJ Rotterdam. (emergency room, doctor or trainer) *

Yes

No rather not

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