Medical information form

Medical Information Form
Universal Challenge Course
Fill out this form completely to allow for your participation on the course
____________________________________ ______________________________
Name
_________________________________ ________________________________________________
Address
____________________________________________________ _____________________________
Organization
Date of Program
____________________________________________________________________________________
Name and phone number of a person to contact in case of an emergency
Allergies: Do you have any allergic reactions (e.g., to bees, drugs, foods, etc.)? If so, what are they?
____________________________________________________________________________________
Medications: Are you taking medication (e.g. Tylenol, Orthonova 777, Proventil, etc.)? If so, what are they? What
are they for? Do you have any medications with you?
____________________________________________________________________________________
Chronic Illnesses: Do you have any chronic illnesses (e.g., diabetes, epilepsy, asthma, etc.)? Please list.
____________________________________________________________________________________

Physical Conditions: Do you have any physical conditions that might limit or prevent you from participating in
certain physical activities? If so, please describe such limitations and conditions on activities.
____________________________________________________________________________________
Injuries: Have you experienced any injuries (e.g., dislocations, sprains, etc.) within the last three years? If so, list
here and identify when the injuries occurred and the extent or the severity of the injury. Have you fully recovered
from this injury?
____________________________________________________________________________________
Physician: Have you been treated by a physician in the past year? Have you been hospitalized within the past
year? If so, please explain.
____________________________________________________________________________________
Primary Physician: Address and Phone Number:
____________________________________________________________________________________
Insurance: Name of Insurance Company. If possible please include your I.D. number.
_________________________________________________________________________________________________________ This form is the property of the Browne Center and will remain as a confidential record. Only the instructors and medical personnel have access to this information. Please return to Dean of Students Office, Brooks School, 1160 Great Pond Road, N. Andover, MA 01845 Release of Liability Form
Universal Challenge Course
Outdoor adventure activities are exciting, challenging and both physically and mentally demanding. Some activities may be stressful and possibly hazardous. The programs provide goal-oriented activities that offer participants an opportunity to explore new behaviors related to trust, teamwork and leadership capabilities. These activities may include field games, low elements a few feet high that are constructed of rope, cable, and wood, and high elements that require safety equipment, water activities, or rock climbing. Instructors who have been specifically trained in the operation and safe practices of challenge courses, water activities, or rock climbing supervise all activities. Our philosophy is Challenge by Choice, meaning that participants agree to choose their own level of challenge and agree not to be coerced by instructors or other participants. The University of New Hampshire has taken precautions to provide proper equipment and qualified instructors. It is impossible, however, to guarantee absolute safety. While it is the aim and responsibility of the program and instructor to provide you with an enjoyable, educational, and safe experience, you must realize that there is a degree of risk and personal responsibility for safety when you participate in adventure activities. You will receive instruction in safe up-to-date practices and safety techniques related to all elements and activities and are supervised throughout the program. Participants are advised to cal hazardous situations to the leader’s attention. Injuries can occur. By consenting to participation, you assume all risks incidental to use of the course and activity, including the possibility of bruises and other more serious injuries. Signing this form indicates you recognition and understanding of the responsibilities and hazards inherent in your participation on the course. You agree to assume all responsibilities and risks involved in the program, and for yourself and your heirs to release and hold harmless the University of New Hampshire, its officers and employees, from all claims and legal actions, whether for property damage, physical injury, or otherwise, arising from your participation in the program. Please confirm with your signature that you have read this information, that you understand your responsibility as a participant, and that you assume the entire risks incidental to the adventure program. Also, sign to show that you have provided us with all the medical information that has been requested on the reverse side that you agree to follow instructions and directions given by your instructor, and that you will act with good judgment. _____________________________________________________________ ____________________________ Name ___________________________________________________________________________________________ Signature Parent or Guardian Signature (if participant is under 18 year of age) Photo Release Form
I hereby grant to the University of New Hampshire and its affiliates, the Browne Center and the New England
Center, permission to use my photographic likeness or videotape of my participation in activities held at the
Browne Center in their promotional, informational, and educational materials.
___________________________________________________ __________________________
Name
___________________________________________________ Signature Please return to Dean of Students Office, Brooks School, 1160 Great Pond Road, N. Andover, MA 01845

Source: http://www.brooksschool.org/ftpimages/277/misc/misc_55251.pdf