HEALTH DISCLOSURE FORM
We require full disclosure of your health. The information you provide may assist us in the event of an accident. Therefore, please
read it carefully; full and accurate completion of all sections is very important. This information otherwise shall be kept
confidentially between the trip leader(s), the Program Coordinator, and health care professionals. We do not use this information
in evaluating your ability to participate in any activities. Only qualified health professionals can make that decision. If you are at
all concerned about your ability to participate in any aspect of the activity, please seek the advice of a health care professional.
By completing this form you are acknowledging your awareness of the above information.
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MERGENCY CONTACT, HEALTH PROVIDER, AND INSURANCE INFORMATION:
PLEASE LIST ALL INFORMATION REGARDING THE FOLLOWING:
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LEASE WRITE BELOW ANYTHING YOU FEEL WE SHOULD BE AWARE OF CONCERNING YOUR HEALTH.
THANK YOU!
Participant Name: _______________________________________ Name of Outing: _______________________________________
Home Address: _____________________________________________________________________ Date: ____________________
Cell Phone: __________________________________________ Other Phone: ____________________________________________
Name: ________________________________________________ Relationship: __________________________________________
Address: ____________________________________________________________________________________________________
Cell Phone: ___________________________________________ Home Phone: ___________________________________________
Doctor’s Name: ________________________________________ Doctor’s Phone: ________________________________________
Doctor’s Address: ____________________________________________________________________________________________
Insurance Company: ____________________________________Policy Number:_________________________ Type: ___________
Gender: _______________ Age: _______ Height: ___’____” Weight: _______(lbs.)
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re you under treatment for any illness or condition? _______ If yes, please name and describe: ______________________________
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Are you currently taking any medication(s)? _______ If yes, please name: _______________________________________________
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Do you have any allergies (food or otherwise)? _______ Are you allergic to bee stings or insect bites? _______ If yes, please explain:
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Do you have any past relevant injuries that may affect your participation? _______ If yes, please name and describe:
___________________________________________________________________________________________________________
Do you have a history of heart problems? ______ If yes, please explain: _________________________________________________
Have you ever undergone surgery? ______ If yes, for what? ___________________________________________________________
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Dietary restrictions (vegetarian, lactose intolerance etc.) _____________________________________________________________
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