Summer High Adventure Health Questionnaire
Participant Information
Participant Name
First Name
Last Name
Age
Gender
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Information
Name 1
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship
Name 2
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship
Emergency Contact Information
Emergency Contact Person
*
Health/Medical Insurance
Company Name
Policy Number
Policy Name
Attach medical insurance card
Browse Files
Cancel
of
Health/Medical Information
Weight (Lb)
Height (inches)
Are you (participant ) currently taking any medications? If yes, please list them below:
Prescription medications will be carried and dispensed by the High Adventure coach for 12-14 year olds. For participants 15 and older how would the parents like us to proceed?
High Adventure coach carries and gives out prescription meds during the trip
Youth carries and takes own prescription meds during the trip
Does the participant have any of the following conditions:
Asthma
Seizures
GI Disorders
Cardiovascular problems
Bone issues
Ear infections
Learning disability
Other
Does the participant have any allergies? If yes, please list them below:
Does the participant carry an epi pen?
Please Select
YES
NO
Does the participant need an asthma inhaler?
Yes
No
Does the participant have any medical or emotional issues that are relevant to a High Adventure trip? If yes, please indicate what they are:
Does the participant wear any implantable medical devices? If yes, what are these devices?
Acknowledgment and Release
I authorize RWF to provide medical treatment performed by the High Adventure coaches if required.
I authorize RWF to carry out emergency measures like first aid, CPR, and medications as needed.
I release RWF for any liability, damage, or cost that can happen like accidents or injuries during the High Adventure trip.
Parent/Guardian Signature
Submit
Should be Empty: