HEALTH STATEMENT

Confidential

This health statement is completely confidential, for use by the Paddle and Trail, ltd  staff.  It is designed to give the facilitators a better picture of who you are so that we can better preparefor and serve your individual needs.  In the unlikely event of an injury, this statement could be the most important information we have about your medical history.....please be as thorough as possible.  THANKS!

Name: __________________________________________

Address:_______________________________________________________________ 

City/State/Zip: ________________________________________________________

Phone:____________________________

Age:_____  Birth Date: ____________ Height:______________Weight:_________________

Insured by:__________________________________  Policy Number:_____________________

IN CASE OF EMERGENCY, PLEASE CONTACT THE FOLLOWING FAMILY MEMBER:

Name: ________________________________   Relationship: __________________

Address: ____________________________________________________________ 

City/State/Zip: ________________________________________________________

Home Phone: ________________________ Work Phone: _____________________

Doctor's Name: ____________________________ Doctor's Phone: ______________

Are you certified in First Aid? __________Type:___________
Expiration Date:_____________

Are you certified in CPR? ______________________ 
Expiration Date:____________________

Can you swim? _________    Level of ability? _______________________________ 

Do you wear glasses? _______ Contacts? __________  

HEALTH HISTORY:

Allergies: (e.g.  insect stings, drugs, foods, etc.)

  Penicillin           Yes _____       No _____        Reaction___________________

  Tetracycline      Yes _____       No _____        Reaction___________________

  Sulfa Proucts    Yes _____       No _____        Reaction___________________        

  Iodine               Yes _____      No _____        Reaction___________________        

  Food                 Yes _____      No _____        Reaction___________________

                        List:____________________________________________________

            Stings/Bites       Yes _____       No _____        Reaction___________________

                        List: ____________________________________________________

            Other               Yes _____       No _____        Reaction___________________

                        List: ____________________________________________________

                                ____________________________________________________

Please check any of the following CONDITIONS (past or present) that could
affect your performance in this activity:

Blackouts ________    Dizziness _________    Chest pain _________   

Headaches__________ GI tract problem _________________  

High blood pressure________  #______/______

Menstrual cramps ________________     Muscle cramps____________________

Other conditions: _____________________________________________________

Blood type: ______________ Date of your last tetanus shot: _________________

Conditions requiring ongoing medical attention/medications:  (e.g. Diabetes, epilepsy, hypo-glycemia, etc.)

_______________________________________________________________

Do you have any physical problems or chronic conditions (e.g.  poor eyes, bad back, knees, etc.) that could affect your participation in these activities?

________________________________________________________________

Do you have any history of heart problems?  If so, please list below.

__________________________________________________________________

Have you had any recent (within last six months) illnesses, injuries, or operations?

__________________________________________________________________

Do you have any fears or phobias that might pertain to activity done with this activity?

__________________________________________________________________

Is there any other information that we should know about? Do you have any disability that would prevent you from participating in the program?

__________________________________________________________________

I understand that during my participation in a Paddle and Trail, Ltd  Program activity, I may be exposed to above-normal risks up to and including death.  I understand, too, that although the Paddle and Trail, Ltd  program has taken precautions to provide proper organization, supervision, instruction and equipment for absolute safety, I also share the responsibility for safety during this event and I assume that responsibility. I agree I will try these activities only under the supervision of Paddle and Trail, Ltd  staff members.  I agree to comply with the facilitators and directions of the Paddle and Trail, Ltd  staff members during this event.

Name of activity: _______________________________________________________________

Signature of Participant:

 _______________________________ Date: ____________________