MEDICAL DISCLOSURE AND ASSUMPTION OF RISK
PROGRAM/DATES:
PARTICIPANT'S FULL NAME:
The following medical information may be necessary in the event of serious illness or accident. Please complete this form accurately.
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:
Name: Relationship:
Email Address:
Home Phone:
Cell Phone:
MEDICAL INSURANCE:
You must have medical/accident insurance that will cover
the expenses of serious illness or accident. List below your
medical/accident ins
urance provider:
DIETARY RESTRICTIONS:
Describe any dietary restrictions (i.e., lactose intolerant,
food allergies)
MEDICATIONS: List all medications you are taking or will be tak
ing during participation in this program. All medicines, prescribed
or over-the-counter, must be transported in their original packaging.
ASSUMPTION OF RISK:
I have co
nsulted with a medical doctor regarding my personal medical needs. I am aware of my personal medical needs.
I assume all risk and responsibility for my medical needs.
There are no health-related reasons or problems that preclude or restrict my participation in this program.
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 its 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
Revised 11-2018
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