UVM Alana Gear MEDICAL HISTORY FORM

UVM Alana Gear
MEDICAL HISTORY FORM
Name:_________________________________ E - Mail:__________________________
Home Address: ___________________________ Home Phone #___________________
Local Address: ____________________________ Local Phone #: _________________
Emergency Contact #1 : _________________________Phone # : ___________________
Emergency Contact #2 : _________________________ Phone # : __________________
Physician’s Name: __
_________________________ Phone # : ____________________
Insurance Company:__________________________ __ Policy # : __________________
Height: _______ Weight: __________ Birth date: _________ M or F : ______________
Belly Button: Innie or Outie: _______
___ Date of Last Physical Exam: ______________
Please answer the following questions:
1. Please list any major illnesses or injuries you have had in the past five years including:
operations, fractures, illnesses and or psychiatric/psychological conditi ons:
2. Please list all major injuries or illnesses which you are currently receiving treatment /
medication for and explain in detail how we can accommodate you.
3. Please list any medications you are currently taking and for what reason. (Includes
Birth Control)
4. Please list any allergies that you have, including: medications, food, plants, and
insects. Please explain in detail the reaction you have and the last time you had a reaction.
5. Please list any other conditions which may affect your performance in the wilderness
environment (i.e. diabetes, heart condition, epilepsy, dietary restrictions, eating disorders,
food allergies)
6. Are you allergic to BEE STINGS? If so, how do you react? If you experience
anaphylactic shock, you must see a physician and carry an anaphylaxis kit with you
throughout the trip.
PLEASE TURN OVER
7. Are you experienced in the course element (hiking, rock climbing, skiing, etc.) that
you have chosen? Please describe past involvement.
8. What do you do to maintain your physical fitness?
9. Have you ever experienced frostbite? Where on your body? When did this happen?
Has it affected your circulation since then?
MEDICAL TREATMENT WAIVER
I hereby authorize UVM Outing Club Leaders, staff members, or other appropriate UVM
personnel to administer or obtain on my behalf first aid, emergency medical care or
admission to an accredited hospital when such care is necessary for the treatment of injuries
sustained while participating in a UVM Outing Club Trip. I hereby give consent to the
administration of emergency medical treatment in the event that I am unable, subsequent to
injury, to give such consent as necessary.
____________________________
_______ _____________________
Name (Printed) Birth date
___________________________________ _____________________
Signature Date
___________________________________ _____________________
Signature of Parent or Guardian (if under 18) Date
UVM Alana Gear
Trip Application & Liability Release Form
Name:________________________________ Major: _____________Class: _________
Local Address:_____________________________________Phone:_________________
Permanent Address:_
______________________________________________________
street town state/zip
E-Mail: ______________________________ Date of Birth: ______________________
Permanent Phone: (
)_________________ Emergency Contact: _________________
Parents or Guardian: __________________
__
Phone Number (
)_________________
I currently carry Medical Insurance? Yes_____ No_____ Group #___________________
Name of Insurance Provider: ________________________________________________
Type of Trip:___________________________ Location:__________________________
THIS IS A WAIVER AND RELEASE OF LIABILITY. PLEASE READ CAREFULLY .
As a participant on a UVM Alana Gear Trip, I realize that inherent dangers exist. While in good health and able to
fully participate in such activities,
I realize my participation may result in illness or injury due to accidents, the
forces of nature or other causes unforeseen. Such illness or injury may include disease, strains, sprains, fractures,
dislocations, paralysis and/or death. By participating, I hereby and knowingly assume all risk resulting from these
activities.
On behalf of myself, my family or other personal representatives I hereby agree to release, hold harmless and
indemnify the UVM Alana Gear, its agents, officers and wilderness leader s from any and all claims and law suits
for bodily injury, property damage, wrongful death, loss of services etc. which may result from my participation in
the above mentioned activities, regardless of whether or not these claims or suits arise from negligent acts,
omissions by the UVM Alana Gear organizers, leaders or facilitators of the activity, employees or volunteers,
another participant, any other person involved or from any other cause.
I HAVE READ THE ABOVE WAIVER AND RELEASE. I UNDERSTAND THAT I HAVE
RELINQUISHED SUBSTANTIAL RIGHTS BY SIGNING IT AND DO SO VOLUNTARILY.
Printed Name: _______________________ Signature:___________________________
Signature of Parent or Guardian
(If participant is less than 18 Years of Age): ________________________
____________
Date: ______________________________