Home Participant Agreement What to Bring

WILD GUYde Adventures: MEDICAL HISTORY Today’s Date:________

Name__________________________________________Gender D.O.B._________

Home Address ___________________________________________________________________

Phone____________________________________ E mail________________________________

Height _______ Weight _______ Do You Swim? _______ Blood Type (if known) _________

Please check any that apply:

Asthma (including exercise induced); do you carry an inhaler? __________

Allergic reactions; please specify: __________ Do you carry an Anakit or Epipen? ______

____ Epilepsy or seizure history; date of most recent incident: ____________________________

Hospitalization/surgery within the last year; please specify, along with general or local anesthetic:

__________________________________________________________________________

____ Regular or recent use of controlled substances (i.e. prescription medication, recreational drugs, alcohol, tobacco, contraceptives, etc.); please specify: __________________________________________________________________________

Diabetes; do you carry insulin? __________

Musculo-skeletal condition; please specify: ______________________________________

Cardio-respiratory disorder; please specify: ______________________________________

Any other known physical limitation; please specify: ______________________________

____ Corrective or protective devices (glasses, joint braces, contact lenses, orthodontia, etc.); please specify: _________________________________________________________________________

Health Insurance Co. Policy No. ________________

Home Phone ______________

Person to notify in case of emergency ____________________Work phone_________________

Address____________________________________ Relationship_________________________