If you answered Yes to any part of the question, please provide details.
If you answered Yes to any part of the Medical History questions above, The Adventure Training Program strongly
recommends that you see a physician before participation.
Do you have Diabetes? Yes___ No___ If you answered Yes, are you dependent on insulin? Yes___ No___
Is there is a history of heart disease in your family? Yes___ No___ If you answered Yes, please elaborate:
Do you smoke? Yes___ No___ Are you a former smoker? Yes___ No___ If you answered Yes, when did
you stop? ___________________________
How often do you exercise? No regular exercise___ 1-2 times/week___ 3+ times/week___
If you lead a sedentary lifestyle, smoke, are overweight, have diabetes or are 45 years of age and have a family
history of heart disease, the Adventure Training Program strongly recommends that you consult your physician
before participation.
If you are unclear about whether to consult your physician or you or your physician would like more information
regarding the activities included in your program, please contact Adventure Training Program staff.
I have consulted my physician. Yes___ No___
My physician advises me that I may participate fully. _____
My physician has advised me to avoid certain activities. ____
My physician advised me not to participate. ____
If your physician has limited or disapproved your participation, please provide further details:
I recognize the inherent risk of injury or disability associated with the Adventure Training Program activities and I
agree to assume that risk. I further agree to follow all of the Adventure Training Program’s safety instructions. I
hereby release the Adventure Training Program, Hudson Valley Community College, its officers, employees, Board
of Trustees, SUNY, and the County of Rensselaer from all liability for any injury to me from participation in the
Adventure Training Program activities. In the event of illness or injury, consent is hereby given to provide
emergency medical care, hospitalization or other treatment, which may become necessary.
In the event of injury or illness, please contact:
Name: __________________________________________ Relationship: ________________________________
Address: _____________________________________________________________________________________
Daytime Phone: ___________________________________ Evening Phone: _____________________________
I understand that failure to answer this questionnaire in a full and comprehensive manner could affect my own safety
as well as that of others, and therefore I affirm that the information herein is accurate and complete. I agree to hold
the Adventure Training Program harmless if full disclosure of a pre-existing medical condition has not been made.
Participant Signature: _______________________________________________ Date: ________________
Signature of Parent or Guardian (if Participant is under 18 years of age): ___________________________________
Name of Workshop: ________________________________ Date(s) of Workshop: _________________________
I hereby grant the Adventure Training Program permission to use, reproduce, or distribute any photographs, films,
videotapes and/or sound recordings of me during my training for use in materials it may create.
Participant Signature: ____________________________ Parent/Guardian Signature: ____________________
I agree that typing my name/student's name in the above fields shall constitute as our signatures on this document.
