Driver Health Questionnaire Please fill out prior to racing! Name DOB Current Medication(s) Current Health Issues Medical Allergies Gender Male Female Blood Type Family Doctor Insurance Provider Emergency Contact Emergency Contact Relationship Emergency Contact Phone # Authorization for use or disclosure of protected health information I understand that my health information will be released ONLY in the case of an emergency and will ONLY be released to those in charge of my care. Magic Valley Speedway may not release this information without your authorization. Filling in your name below, allows Magic Valley Speedway to do so, again, only in the case of an emergency. Your Full Name Witness Date Send