MICHIGAN TECHNOLOGICAL UNIVERSITY
CHALLENGE COURSE
ADULT MEDICAL INFORMATION AND LIABILITY WAIVER
Disclosure
Michigan Technological University Challenge Programs involve a variety of activities in both indoor and
outdoor settings. Activities include warm-ups, games, group initiative problems, low ropes course
elements, and other rigorous physical adventure activities. These activities have deliberately and
consciously been chosen to place program participants in challenging settings that elicit some fresh
behaviors, some anxiety, and some new insights. The goal of Challenge Programs, which is to raise
participant awareness about themselves and others through challenge, is thus supported by program
activities.
All activities are presented on a “Challenge by Choice” basis. This means that the level of participation is
up to the individual’s choice. Yet there is a risk, which much be assumed by each participant, that due to
the demands of certain activities he or she may incur injury. There are certain risks inherent in outdoor
adventure.
The information gathered on this medical form is intended to help inform Challenge Program staff of any
pre-existing medical conditions, and to help determine if consultation with your physician is
recommended prior to your program. If you have a pre-existing condition, participation in some of the
more strenuous activities may not be recommended. This information will be kept in strict confidence by
Michigan Technological University and only shared with your permission.
I. GENERAL INFORMATION (PLEASE PRINT)
Your Organization______________________________________ Date of Program:_______________
Name:___________________________________________________ Age:_______
Address__________________________________________________ Phone______________________
Sex F____ M ____ Height ____________________Weight ______________
DO YOU HAVE HEALTH/ACCIDENT INSURANCE ?
If yes, give the name and address of
company__________________________________________
_______________________________________________________________________
If no, the following acknowledgement of risk statment must be signed in order for you to
participate: I have no health insurance. I realize the risk I am taking and any injury I may
receive is my responsibility.
Signature______________________________________________ Date____________________
PLEASE CHECK THE BLANK IN FRONT OF ANY OF THE FOLLOWING CONDITIONS THAT
APPLY:
___Asthma
___Dislocations
___Blood Problems
___Back Problems
___Joint Problems
___Vision Problems
___Epilepsy
___Heart Problems
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___High Blood Pressure
___Diabetes
For any conditions checked above, please describe symptoms/conditions, how often they occur and how
long they last, how you care for them, including any medications you carry for the above indicated
conditions:
Do you have any limiting physical or health disabilities or handicaps (temporary or permanent) that you
or your doctor feel would limit your participation in this program? Explain:
Have you had any recent (up to 12 months) acute illness, injury or surgery?
Last date of occurrence:
Give details and how it might affect your participation:
___Do you get cold easily? Explain:
___Are you pregnant? Describe condition and give due date:
___Are you currently under a doctor's care? Explain:
___Are you taking medication (prescribed or not, e.g. cold medicine)? If so, what type, what is it for?
___Allergies: If you are allergic to any of the following, please explain.
___ Medications: Please specify:
___ Foods: Please specify special dietary needs:
___ Insect bites/stings or family history of same. If allergic, please carry your allergy medicine.
___ Other allergies:
___NONE OF THE ABOVE MEDICAL CONDITIONS APPLY TO ME.
Person to Contact in Case of Injury or Illness:
Name_____________________________________________________
Relationship______________________
Address_____________________________________________________________________________
_______
Phone Numbers: Home________________________________
Business________________________________
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II. MEDICAL HISTORY
Do you currently have OR have you any history of the following:
___heart disease
___heart palpitations
___chest pain or pressure
___heart attack
___heart murmur
___stroke
___high blood pressure
___currently on medication for high blood pressure
___any of these symptoms with exertion
If you checked any of the above blanks, please provide additional information:
III. ADDITIONAL FACTORS
Do you have diabetes? ___yes ___no
If yes, please indicate if it is:
___insulin dependent diabetes ___non-insulin dependent
Is there a history of heart disease in your family? ___yes ___no
If yes, please explain:
Do you smoke?
___yes ___no
Are you a former smoker?
___yes ___no
How long ago did you quit? ________________________________________________________
Indicate your level of fitness:
___little or no exercise on a regular basis
___occasional exercise, 1 or 2x a week
___vigorous exercise (e.g., 20 minutes of running, fast walking or equivalent) 3x a week or more
PHYSICIAN CONSULTATION
If you checked any blanks in Part Two, Medical History, we strongly recommend that you consult with
your physician prior to participating in a Challenge Program or other strenuous physical activity. These
conditions include a personal history of heart disease, chest pain or pressure, high blood pressure, or
stroke.
Diabetes, smoking, sedentary life style, being overwight, family history of heart disease and age (over 45)
are also recognized as cardiac risk factors. If you have three or more of these risk factors, we strongly
recommend that you consult with your physiciian prior to participating in a Challenge Program or other
strenuous physical activity.
This medical information form is intended to help prespective participants determine who may need to
consult with theri physician prior to participation. If you are uncertain about any pre-existing medical
conditions, we strongly recommend that you conslult with your own physician prior to participatin in a
Challenge Program. If you or your physician require additional information about activities in any
particular Challenge Program, please contact us.
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In preparation for this Challenge Progam, I have consulted with my physician: ___yes ___no
If yes (check one):
___I have been advised that I may participate fully in the Challenge Program without limitation
___I have been advised that I should not participate in the Challenge Program
___I have been advised that I may participate in the Challenge Program, but should avoid certain
activities.
Please explain and provide additional information:
II. RELEASE OF LIABILITY
I affirm that the confidential medical information which has been provided is accurate and complete. I
understand that failure to disclose this information could affect my own safety and those around me, and I
agree to hold Michigan Technological University harmless if full disclosure of a pre-existing medical
condition has not been provided. In the event of illness or injury, consent is hereby given to provide
emergency medical care, hospitalization or other treatment which may become necessary.
I understand that parts of the Challenge Program may be physically or emotionally demanding. I hereby
acknowledge that I am aware of these risks and I agree to follow all safety instructions and ask questions
if I do not understand. I also acknowledge that, despite careful precautions, there are certain inherent
risks of injury in this program, and I accept those risks. I understand that each participant must assume
the risk of injury or disability that could result from any of the activities.
I release and agree to hold harmless Michigan Technological University, its Board of Control, officers
and employees from any against any and all claims and causes of action arising our of my (or the minor
student’s) participation in this program or any personal or bodily injury incurred while participating in the
program excepting only if such claimed injury arises out of the intentional misconduct by Michigan
Technological University, its officers, agents or employees. If signed as a parent or guardian this release
is on my own behalf and on behalf of the minor student.
I have read and I understand this statement.
Date
Participant Signature
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