Health Statement Form printable pdf download

OUTDOOR WILDERNESS LEARNING CENTER

HEALTH STATEMENT

The proposed activity provided by the Outdoor Wilderness Learning Center, including participation in challenge course activities, requires participation in

physical exercises which are, by their nature, physically demanding. Many of the activities will challenge you, and cause surges in blood pressure and

pulse rates. It is imperative that you are free of any heart related or other diseases. Therefore, all participants must be free of medical or physical

conditions, which might create undue risks to themselves or any others who depend on them. Good physical condition will increase your enjoyment of the

outdoor activities. If there is any doubt about your ability to safely participate in this experience, you should have a physical examination.

Name

___________________________________________________________ Birth Date__________________

S.S.#

___________________________________________________________ Gender

__________________

Address

___________________________________________________________ Age

__________________

City, ST, Zip ___________________________________________________________ Work Ph. __________________

Home Phone ___________________________________________________________ Date of last physical exam_____

Name of Physician ______________________________________________________ (must be within the last 12 months)

Physician’s Ph. __________________________________________________________

In an emergency notify: __________________________________________________

Home Address

__________________________________________________ Home Ph.__________________

City, ST, Zip

__________________________________________________ Work Ph. __________________

Work Address

__________________________________________________ City, ST, Zip ________________

Health History: (Circle the appropriate answer and describe any YES answers.)

Have you had or do you currently have any heart or heart related problems (dates):

YES

____________________________________________________________________

Do you frequently suffer from pains in your chest: ____________________________

YES

Do you often feel faint or have spells of severe dizziness: ______________________

YES

Has a doctor ever told you that you have high blood pressure: ___________________

YES

Are you a smoker: ______________________________________________________

YES

(Note: If you have had any heart related problems you will need to have a release from a physician in order to participate in these

activities.)

Do you have arthritis, joint or back problems that might be aggravated by exercise:

YES

_____________________________________________________________________

Have you had any operations or serious injuries (dates):

YES

_____________________________________________________________________

Do you have any disabilities or chronic recurring illness or communicable diseases:

YES

_____________________________________________________________________

Are there any activities to be limited / discouraged by physician’s advice:

YES

_____________________________________________________________________

Are you allergic to any medicines, insects or pollen:

YES

_____________________________________________________________________

Do you have Epilepsy: __________________________________________________

YES

Do you have Diabetes: __________________________________________________

YES

Do you have any prescribed meal plan or dietary restrictions: ____________________

YES

Are you currently sick and / or using a medication that is not listed above: __________

YES

______________________________________________________________________

Do you carry family medical / hospital insurance: ______________________________ YES

Carrier: ________________________________ Policy Number: ______________________________________________

Suggestions or health related information for O.W.L. Center personnel:

General Health Statement:

REPRESENTATION AND EMERGENCY AUTHORIZATION

This health history is correct so far as I know, and I believe that my health is satisfactory to participate in the challenge course activities.

I hereby give my permission to the medical personnel selected by the staff of the Outdoor Wilderness Learning Center (O.W.L. Center) to order injection

and / or anesthesia and / or surgery for me. Such authorization for emergency treatment shall also include, but not be limited to, charges incurred for the

providing of aid and arranging evacuation if the staff of the O.W.L. Center determine that such evacuation is necessary or desirable. I further agree to

assume responsibility for the costs of any specialized means of evacuation and of any medical care and acknowledge that these costs are the financial

responsibility of the undersigned. I also understand and agree to abide by any restrictions placed on my activities.

Name of Participant:

Date:

Signature of Participant (eighteen years of age and older):

Signature of Parent or Guardian (if under eighteen years of age):

Witness:

Date: