Experiential and Adventure Program Statement of Health Form

Participant

Name:

Date of Birth:

Gender:

Height:

Weight:

Contact

Phone:

Emergency Contact:

Emergency Phone:

Emergency Relationship:

Health Information

Doctor's Name:

Clinic:

Clinic's Phone:

Health history:

Describe conditions, treatments where possible, allergies (ex. insect stings, drugs, food)

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

Conditions requiring regular medication:

Diabetes, Epilepsy, etc.

Name and dose of medication:

Recent injuries, illness, and/or operations:

Other physical disabilities or chronic or physical conditions:

Heart or back problems, high blood pressure, etc.

Emotional or behavioral disorders:

Phobias, etc.

If the person named in the Participant section of the Health form is underage, they must have a parent or guardian electronically sign the document generated from submission.

Once you click the submit button an electronic document requiring a signature will be generated.

Full Name of Signer:

Parent/Guardian of minor if applicable

If you are human, leave this field blank.

Phone

(920)490-3846

FAX

(920)490-3899

Mailing Address

PO Box 365
Oneida, WI 54155

Location

2640 West Point Rd
Green Bay, WI 54304

Contact

Mark Steinbach, Director
(920)490-3846
msteinba@oneidanation.org

Additional/Contact Info