Medical And Physical Condition Standard Information And Medical Release Form printable pdf download

MEDICAL AND PHYSICAL CONDITION STANDARD INFORMATION

AND MEDICAL RELEASE FORM

_____________________________________, (client), as lawful consideration for

(please print)

participating with Skyline Outfitters, LLC furnish the following, health, and dietary information

to the Skyline Outfitters, LLC which I state to be true and correct, and accepting responsibility

for failure to disclose any condition of not fully stating such condition. I have assumed full

responsibility for my physical condition; that the use of all services and/or facilities of the

Skyline Outfitters, LLC is at my own risk and that supplying this information is for the sole

purpose of Skyline Outfitters, LLC in planning the services and/or facilities and I hold Skyline

Outfitters, LLC harmless if any liability resulting from my personal health or fitness. I further

understand that I must furnish complete information to include physician’s reports if the

conditions would otherwise be considered to be detrimental to my health if not disclosed. I will

attach other sheets if necessary to full disclose my condition(s). I also understand that I am

signing an additional release and assumption of risk form.

Client signature:_________________________________________

Date:______________Age:______Weight:________Height:________

Have you ever had or been diagnosed as having heart or coronary artery disease?

Yes______No______

If yes, please use the back of this page to describe any limitations on activities, medications of

other relevant information.

Do you suffer from high blood pressure? Yes______No______

If yes, please describe any limitations on activities, medications of other relevant information

on the back of this page.

Any other condition that requires taking of daily medications or carrying of special medications

or equipment? Yes_____No_____

If yes, describe condition, medications or equipment required, any restrictions caused by the

same, and any special instructions needed by the outfitter on reserve side.

Do you have any allergies, including allergic reactions to specific medications, specific foods, or

other physical condition that requires special attention or medication? Yes______No______

If yes, describe condition and/or medication on the back of the page.

Do you have any dietary restriction? Yes______No______

If yes, please describe on back of page. Do you have any specific requests for food or beverages

at camp?

Medical And Physical Condition Standard Information And Medical Release Form