Health Form
Landmark programs involve a variety of activities including warm-ups, games, group initiative problems, low ropes
elements and hands on application of CPR/first aid training. Some programs may also include other rigorous physical
adventure activities such as backpacking, climbing, caving, paddling, swiftwater rescue, swimming, or hiking. These
activities are designed to be within the limits of a person who is in reasonable good health. The level of participation in
all programs and activities is at all times completely up to the individual.
Safety is a high priority in all programs. In addition, each participant must assume the risk that he or she may suffer an
emotional or physical injury and disability. Each participant must have health/accident insurance coverage. The
information requested on this form is intended to help alert staff to pre-existing medical conditions. This information will
be held in confidence. Please complete the form below and bring it with you on the day of your scheduled program.
General & Medical Information
Name____________________________________________________________ DOB____________________
Do you have health/medical insurance? No Yes
Name & Address of Company:
Do you have any limiting physical or health disabilities - temporary or permanent - that you or your doctor feel would
limit your participation in a Landmark activity? No Yes
Do you have any chronic or recurring injuries? No Yes
Are you currently taking any medication? No Yes
Do you have any allergies or reactions to any medications, plants, or insects? No Yes
Have you had surgery in the past year for any condition which may limit your participation? No Yes
Do you have asthma? No Yes
Do you have diabetes? No Yes
Are you pregnant? No Yes
If yes to any of the above, please explain/describe:
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Do you have or do you have a history of:
_____ high blood pressure _____ currently on medication for high blood pressure
_____ heart palpitations _____ chest pain or pressure _____ stroke
_____ heart attack _____ heart disease _____ heart murmur
If yes to any of the above, please explain/describe:
Please list any other concerns or conditions that may affect your participation:
We strongly recommend that you consult your physician or midwife if you are pregnant or have
checked off any of the conditions above before participation in Landmark activities .
Emergency Contact Information
Person:_________________________________________________Relationship to you:_______________________
Phone Numbers:__________________________ __________________________ __________________________
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