Asbury Hills Release Form - Asbury Hills (Page 2 of 2) in pdf

PARTICIPANT HEALTH INQUIRY

This form is intended to remind staff and participants of the seriousness of attempting challenge activities with a pre-

existing medical condition and to aid our facilitators to best serve you. This information will be confidential.

Name: _____________________________________ Date of Birth: _______________________________

Address: _____________________________________________________________________________

City ____________________________ State: ________________________ Zip: ____________________

Home Phone: ________________________________ Business Phone: _____________________________

Person to notify in case of accident and/or injury:

Name: _________________________________ Phone Number: ____________________________

Do you have any of the following conditions that might limit your involvement in physical activities?

YES

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Pre-existing medical conditions (past surgeries)…..…………………………………………..

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

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Heart conditions (murmurs, irregular heartbeat, shortness of breath, chest pain)………...



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High blood pressure………………………………………………………………………..........



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Asthma……………………………………………………………………………………………..

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Allergies (food, bees, insects, or medicines)…………………………………………………..



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Problems with neck, back, arms, ankles, or knees……………………………………………

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Suffer from severe headaches, dizziness, or fainting……………………………………......

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Seizures……………………………………………………………………………………………



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Diabetes……………………………………………………………………………………………

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FOR FEMALES: Pregnancy……………………………………………………………………..

If yes to any of the above conditions, please explain:

_________________________________________________________________________________________________

Describe your current level of physical activity:

_________________________________________________________________________________________________

Participant – please read and sign

I have honestly disclosed to the staff any medical, psychological, or personal information relating to my health. I will

remember that a challenge by choice atmosphere exists at all times, and I should not feel pressured to participate.

_______________________________________________

______________________

Signature

Date

Asbury Hills Release Form - Asbury Hills Page 2

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