MEDICAL DISCLOSURE AND ASSUMPTION OF RISK
PROGRAM/DATES:
PARTICIPANT:
The following medical information may be necessary in the event of serious illness or accident. Please complete this form accurately
and truthfully. The facts you disclose will be kept confidential and will be used only to help the staff respond to an injury or illness.
Failure to disclose accurate and complete information could compound the seriousness of an accident or illness, particularly if you are
unable to respond clearly to the medical staff's inquiries. Please print your responses.
PERSON TO CONTACT IN EVENT OF EMERGENCY (parents or nearest relative)
Name: Relationship:
Home Phone: Cell Phone:
Office Phone: email:
MEDICAL INSURANCE:
You must have medical/accident insurance that will cover
the expenses of serious illness or accident. List below your
medical/accident insurance provider:
DIETARY RESTRICTIONS:
Please describe any dietary restrictions (i.e., lactose
intolerant, food allergies)
MEDICATIONS: List all medications you are taking or will be taking during this program. All
medicines, prescribed or over-the-counter, must be transported in their original packaging.
BLOOD TYPE
RH FACTOR:
Assumption of Risk
I have consulted with a medical doctor with regards to my personal medical needs. I am aware of all applicable personal medical
needs. There are no health-related reasons or problems that preclude or restrict my participation in this program. I assume all risk
and responsibility for my medical needs.
The University may, but is not obligated to, take any actions it considers to be warranted under the circumstances regarding my
health and safety. I agree to pay all expenses relating thereto and release the University from any liability for their actions.
Signature of Participant:
Participant’s Signature Printed Name Date
Parent/Guardian’s Signature Printed Name Date
Signature of Parent
or Guardian if
participant is a minor:
Parent/Guardian’s Signature Printed Name Date
