Core Medical Information Page 2
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2CURRENT PHYSICAL ACTIVITY: List any physical activities you engage in, including the frequency, duration and level of
intensity. None
Approximate
Level of Intensity
Leisure
Moderate
Intense
Activity
Frequency
Time/Distance
SWIMMING ABILITY:
Very Good
Nonswimmer
Poor
Fair
Good
ADDITIONAL INFORMATION: Please list any additional information you think important for your leaders to know.
None
HEALTH INSURANCE INFORMATION:
Participants must carry personal health/medical insurance. CORE does not provide this type of insurance for participants.
Health Insurance:___________________________ Policy Holder:____________________ Policy #:__________________
EMERGENCY CONTACT INFORMATION:
PARTICIPANT CONTACT INFORMATION:
ID#:____________________
____________________
Campus Address:_________________________________ City:
State: _____Zip:___________
Home Address: __________________________________ City:______________________ State:_____ Zip:___________
Campus Phone: (
)__________________Home Phone: (
)__________________ Email: _______________________
IN THE EVENT OF AN EMERGENCY PLEASE CONTACT:
Emergency Contact’s Name: __________________________________ Relationship: _______________________________
Daytime Phone: (
)_________________________ ____ Evening Phone: (
)____________________________
Emergency Contact’s Name: __________________________________ Relationship: _______________________________
Daytime Phone: (
)_________________________ ____ Evening Phone: (
)____________________________
CONSENT FOR EMERGENCY MEDICAL TREATMENT
I, ________________________, give consent for any emergency hospitalization, anesthesia, operation, field evacuation or other
medical treatment which might become necessary while participating in this activity.
Signature:__________________________________________________________ Date:______________________
Parent/Guardian Signature (under 18):______________________________________________Date:______________
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Parent category: Medical