Aspen Creek Adult Medical Form/Waiver

Adult Medical Form
ADULT INFORMATION
Full Legal Name
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender

Other
School or Group Name
Trip Dates
School Role/Position
HOME CONTACT INFORMATION
Home address
City State Zip
Cell phone
Format: (000) 000-0000.
Email address
example@example.com
Additional phone number
Format: (000) 000-0000.
ADDITIONAL EMERGENCY CONTACT INFORMATION
Name of emergency contact
Relationship
Home address City State Zip
Phone number
Format: (000) 000-0000.
Email address
example@example.com
Additional phone number
Format: (000) 000-0000.
MEDICAL INFORMATION
Primary Physician
Phone
Format: (000) 000-0000.
Address
Health Insurance Company
Policy
MEDICAL HISTORY: Describe and provide dates for any known medical history of which Cal-Wood should be aware (asthma, diabetes, seizures, heart disease, physical injuries, bleeding/clotting disorders, psychiatric treatment, sleep disorders, etc.)
ALLERGIES: List any known source of allergies including environmental allergies, drugs/medications, insect stings or bites, penicillin, hay fever, iodine, dogs/cats, diphenhydramine, etc.)
FOOD ALLERGIES / DIETS: List any known food allergies or restricted diets that you must follow at Cal-Wood. (peanuts, tree nuts, shellfish, dairy, etc. / vegetarian, vegan, celiac, no pork, kosher, etc) * Cal-Wood aims to accommodate different dietary needs, but strongly restricted diets may require students to supply their own food.
MEDICATIONS: List all medications their dosage and their purpose that will need to be taken while at Cal-Wood.
PHYSICAL LIMITATIONS: List any physical activity from which you need to be excused and for what reason (ex jumping- injured knee, running- severe asthma, climbing- shoulder surgery, etc.)
Responsibility + Liability Waiver
Adult Chaperone Responsibilities:

Please read the following responsibilities, agreeing that you are capable and willing to complete each of these tasks. Please contact the Lead Teacher as soon as possible if you are unable or unwilling to perform any of these duties:

A. I will be at Cal-Wood for the duration of the program.

B. I understand that I am a volunteer and will actively participate and be available as needed.

C. I understand that there is no compensation for my participation in this program.

Understanding of Program and My Role as a Chaperone I have read the information above and I understand the information concerning my role as adult supervisor for the visiting school. I am aware that I will be needed to supervise students. Furthermore, I declare that I do not have any history of child abuse (physical or emotional) and I will be a positive role model to all students during the Cal-Wood school program.

By signing this, you also agree to review the Chaperone Handbook (English/Spanish) and Chaperone Video PRIOR to your trip.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Liability Waiver/Authorization for Medical Treatment

I understand the nature of Cal-Wood programs and recognize that there are inherent risks in such outdoor activities. Further, I release Cal-Wood and the Pilot Trust*, and all members of their staffs, individually and collectively, from any liability or obligation for any such medical or other health care expenses and do hereby agree to hold Cal- Wood/Pilot Trust and all members of their staffs harmless from any claim, demand, or expense, including attorney fees, arising out of any injury, illness or other disorder of any kind, which may be suffered by the participant as a result of attendance at Cal-Wood School Program. *Note: Pilot Trust is the property owner. I understand the nature of Cal-Wood school programs and recognize that there are inherent risks in such outdoor activities.

I assume full responsibility for the information provided about my health. I give permission to Cal-Wood staff to call a doctor or emergency medical service and for the doctor, hospital, or medical service to provide emergency medical or surgical care should an emergency arise. It is understood that Cal-Wood staff will make a conscientious effort to locate the emergency contacts listed on this form before any actions will be taken and I will accept the expense of emergency treatment.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Media and Email Authorization

I agree that the use of my email will subscribe me to Cal-Wood's communications and any photographs taken by Cal-Wood staff of the participant shall be the property of Cal-Wood and may be used by Cal-Wood at its discretion for any publicity, marketing, evaluation, and advertising purposes. I hereby consent to and authorize such use without restriction.

*If you need an exception to the media and email release, let us know via email: schoolprograms@calwood.org.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Additional Notes
Should be Empty:

Adult Medical Form

ADULT INFORMATION

HOME CONTACT INFORMATION

ADDITIONAL EMERGENCY CONTACT INFORMATION

MEDICAL INFORMATION

Responsibility + Liability Waiver