Experiential and Adventure Program Statement of Health eSignature


Participant

Name:  

Date of Birth:  

Gender:  

Height:  

Weight:  

Contact

Phone:  

Email:  

Emergency contact:  

Emergency phone:  

Emergency relationship:  

Health Information

Doctor's Name:  

Clinic:  

Clinic's Phone:  

Health history:

If you need to carry a Epinephrine please inform instructors where you keep it.

Conditions requiring regular medication:

Name and dose of medication:
 

Recent injuries, illness, and/or operations:

Other physical disabilities or chronic or physical conditions:

Emotional or behavioral disorders:

Leave this empty:

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Signature Certificate
Document name: Experiential and Adventure Program Statement of Health eSignature
lock iconUnique Document ID: a7a47054e1808d601e761b8080472270c521cc51
Timestamp Audit
July 27, 2021 9:53 am CDTExperiential and Adventure Program Statement of Health eSignature Uploaded by Oneida Nation - webmaster@oneidanation.org IP 74.62.93.28
July 28, 2021 1:04 pm CDTAdventures Program - adventure_dept@oneidanation.org added by Oneida Nation - webmaster@oneidanation.org as a CC'd Recipient Ip: 74.62.93.27