Medical Information Form - Adventure Recreation Programs
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1Nickname/Name Gone By
______________________
MEDICAL INFORMATION FORM
- ADVENTURE RECREATION PROGRAMS
PARTICIPANT INFORMATION (PLEASE PRINT)
I.
Name ______________________________________________
Today’s Date ____________________
Local Address ___________________________________________________________________________
City/State/Zip ___________________________________________________________________________
Local phone number where you can be reached:
(_____) _____-________
Male ____ Female ____
Birth Date ____/____/________
Height _____ Weight _____
Smoker: YES
NO
Emergency Contact: _________________________________
Relation to Participant: ______________
Home Phone: (_____) _____-________ Cell Phone: (_____) _____-________ Work Phone: (_____) _____-________
MEDICAL INFORMATION
II.
Date of last Tetanus Booster ____/____/________
List any medication to which you are allergic: __________________________________________________________
_______________________________________________________________________________________________
List any other allergies (food, plants, bee stings): _______________________________________________________
_______________________________________________________________________________________________
Do you require and/or carry any medications for allergic reactions (circle one)? YES
NO
If yes, please list what you are carrying with you on the activity: __________________________________
Adventure Recreation staff are trained to assist participants who are PRESCRIBED with epinephrine auto-injectors in
the event of an allergic reaction that progresses to a life threatening stage. Adventure Recreation DOES NOT carry
epinephrine auto-injectors or administer epinephrine to participants without prescriptions.
Do you have any current and/or on-going illness or condition such as diabetes or high blood pressure? YES NO
If yes, please list: ________________________________________________________________________________
Do you require and/or carry medication? YES
NO
If yes, please indicate:_____________________________________________________________________________
Please list any joint or orthopedic problems you have: __________________________________________________
_______________________________________________________________________________________________
Please indicate any history of heart problems including hospitalization, and treatment dates: ___________________
_______________________________________________________________________________________________
INSURANCE
III.
Are you covered by any Hospitalization or Medical Care Policy?
YES
NO
If yes, name of insurance company issuing the policy:____________________________________________________
Policy or certification number:______________________________________________________________________
SIGNATURE (IF PARTICIPANT IS UNDER 18 YEARS OF AGE, PARENT OR GUARDIAN MUST SIGN)
IV.
I fully understand the rigorous nature of the program that I am participating in. In the event of an accident or
emergency that renders me unable to communicate, I grant my permission for any medical care, operations, and/or
anesthesia, which might become necessary.
Signature: _____________________________________________________
Date: ____/____/________
Parent/Guardian Signature: _______________________________________
Date: ____/____/________
(Must be signed by parent or guardian if participant is under the age of 18 )
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