UNC OUTDOOR PURSUITS
Participant Information
Name:___________________________________
Bear ID #:_______________________________
Address:_________________________________
Phone #:________________________________
Email:___________________________________
Date:__________________________________
Gender:
Male
Female
Emergency Contact Information
Name:____________________________________
Relationship:____________________________
Phone#:___________________________________
Allergy Information
Type of Allergies: Check all that apply and list specifics.
Medication:___________________________________________________________________________
Food:________________________________________________________________________________
Insect Bites / Stings:____________________________________________________________________
Environmental Allergens :_______________________________________________________________
Symptoms of Allergy: Check all that apply
Hives
Shock
Swelling of ___________________________
Fainting or Dizziness
Difficulty breathing
Difficulty swallowing
Other:_______________________________________________________________________________
Medical History
1.
List any medications that you are currently taking.
2.
Have you been hospitalized within the past year or within the past year have received treatment for any medical
event or condition? If so, please describe fully.
3.
If you now have, or have had any of the following symptoms or conditions, please circle “yes” and underline the
specific condition. If not, circle “no”.
a. yes no
dizziness, recurrent headaches, or change in level of consciousness
b. yes no
eye, ear, nose, throat, tonsils, or sinus symptoms
c. yes no
impairment of sight, hearing, or speech
d. yes no
chronic cough, bronchitis or asthma, coughing up of blood, or contact with tuberculosis
e. yes no
chest pain, shortness of breath, palpitation, ankle swelling, heart murmur, heart disease, high or low
blood pressure
f. yes no
reaction to bee stings
g. yes no
sensitivities/allergies to: horse serum (tetanus antitoxin), sulfa, penicillin, or any other drugs
_______________________________________________________________
h. yes no
symptoms relating to the gastro intestinal tract (i.e. diarrhea, recurring
abdominal pain, passing of blood, ulcer of stomach or duodenum)
i. yes no
severe menstrual cramps or menstrual problems
j. yes no
albumin, sugar or blood in urine; kidney stone, frequency in urinating, bed wetting, or other urinary
difficulties
k. yes no
muscle. joint, knee or back pain, bursitis, arthritis, sciatica
l. yes no
muscle or limb weakness, numbness, or tingling
m. yes no
benign or malignant growth or tumor
n. yes no
history of diabetes, thyroid imbalance, hypoglycemia
o. yes no
dietary restrictions (i.e. diabetic, low cholesterol, vegetarian, etc.)
p. yes no
episodes of depression., anxiety, hysteria, nervousness
q. yes no
currently pregnant
Health Insurance Information
Outdoor Pursuits adheres to the University Policy concerning Health Insurance which states:
-
It is a policy of the UNC Board of Trustees that all students who are enrolled for 9 credit hours or more are required to
have health insurance. This is to ensure that health care costs will not interfere with your academic goals
All students with 9 or more semester hours on the Greeley campus are automatically enrolled in the university student
health insurance plan and billed along with other university services.
If you have other comparable insurance, you must show proof of insurance and submit an online waiver by the 10th
day of classes
Please mark your current health insurance status:
UNC Student currently taking 9 or more credit hours and enrolled in the University Student Health Insurance Plan.
OR
UNC Student with comparable insurance (must have completed “UNC Student Health Insurance Plan Online
Waiver” through URSA).
Authorization for Emergency Medical Care
I am aware of my past and present health and fitness in relationship to strenuous activity. I will participate in all
course activities except for those noted below by myself and/or my physician. Information about any and all
prescription drugs that I am currently taking is noted.
Should an accident or emergency occur that renders me unable to communicate, I hereby give permission to the
present Outdoor Pursuits / Campus Recreation staff members to call and communicate with emergency medical
personnel, except as noted; ______________________________________________________________________
_____________________________________________________________________________________________
I have completed the above form to the best of my ability with full knowledge that any information with held may
create the potential for serious injury or re-injury. My participation in an Outdoor Pursuits program will be determined
based on a review of this form. Failure to submit this form will mean that you may be an observer, rather than a full
participant. Regardless of your physical condition, you are expected to pay attention to your body and its physical
limitations to select an appropriate level of participation. Failure to complete all portions of this form could result in
injury or compound the damage to an existing injury.
Participant Signature: ___________________________________
Date: _____________________
Guardian Signature (if participant is under 18): ___________________________
Additional signature required on opposite side of page.
Acknowledgment of Receipt of Privacy Practices
I, _____________________________________________have received a copy of the University of
(Print Name)
Northern Colorado Notice of Privacy Practices with an effective date of 7/27/10
___________________________________________ ___________________________
Signature of Participant
Date
RELEASE OF IMAGE, LIKENESS AND/OR VOICE RECORDINGS
I hereby grant the Board of Trustees of the University of Northern Colorado (“UNC”) permission to take
photographs, video and/or audio recordings of my participation in UNC Outdoor Pursuits trips, activities
and seminars including, but not limited to _____________________ (collectively “Events”). I grant UNC
permission to use negatives, prints, motion pictures, video and/or audio recordings, or any other
reproduction of the Events that contain my image, likeness or voice for educational and/or promotional
purposes in any UNC written, video and/or audio materials of any type or manner including but not
limited to books, magazines, flyers, manuals, handbooks, catalogues, in hard copy, any electronic or
digital format and/or on the World Wide Web, or in any other manner in the sole discretion of UNC. I
grant this permission effective on the date written below and in perpetuity. I understand that I cannot,
at any time, revoke the permission that I have given to UNC by signing this RELEASE OF IMAGE, LIKENESS
AND/OR VOICE RECORDINGS.
I declare that I have read and understand the contents of this RELEASE OF IMAGE, LIKENESS AND/OR
VOICE RECORDINGS, and I am signing it as my free and voluntary act, irrevocably binding myself and my
heirs, successors and assigns.
Date
Signature
Legal Guardian Signature:
Date:
(Parent or legal guardian must sign if participant is under 18 years of age)
UNC OUTDOOR PURSUITS
READ THIS DOCUMENT COMPLETELY BEFORE SIGNING. ITS EFFECT IS TO RELEASE THE UNIVERSITY OF
NORTHERN COLORADO FROM ANY LIABILITY RESULTING FROM YOUR PARTICIPATION IN THE
ACTIVITIES DESCRIBED BELOW AND WAIVES ALL CLAIMS FOR DAMAGES OR LOSSES AGAINST THE
UNIVERSITY.
_______________________________________________________________________________
RELEASE FROM RESPONSIBILITY, ASSUMPTION OF RISK AND WAIVER
In consideration of my being permitted by the University of Northern Colorado to participate in UNC
Outdoor Pursuits events I, ____________________________, am exercising my own free choice to
participate voluntarily in the Outdoor Pursuits activities, and promising to take due care during such
participation, hereby release and discharge, indemnify and hold harmless the State of Colorado acting
through the Board of Trustees of the University of Northern Colorado, and their officers, agents,
employees, and any other persons or entities acting on their behalf, and the successors and assigns for
any and all of the aforementioned persons and entities, against all claims, demands, and causes of
action whatsoever, either in law or in equity, relating to injury, disability, death or other harm, to person
or property or both, arising from my participation in and/or presence at the events.
I acknowledge that I am aware of any hazards and risks which may be associated with my participation
in the events. I understand, accept, and assume those hazards and risks, and waive all claims against
UNC. I understand that I am solely responsible for any costs arising out of any bodily injury or property
damage sustained through my participation in normal or unusual acts or conduct associated with the
events.
I have had sufficient time to review and seek explanation of the provisions contained above, have
carefully read them, understand them fully, and agree to be bound by them. After careful deliberation, I
voluntarily give my consent and agree to this Release, Assumption of Risk and Waiver. I certify that I am
over the age of eighteen years, and have read and executed this document on the ______ day of
_________, 2014.
_____________________________________
Signature
_____________________________________
Witness
If participant is under the age of 18, his or her parent or legal guardian must also sign.
I, (printed name) ____________________________________, am the parent or legal
guardian of the student who has signed above. I have read and understand the
provisions of this document, I consent to the student participating in the events, and I
fully enter into and agree to the above Release From Responsibility, Assumption of Risk
and Waiver.
_______________________________
Signature of Parent or Legal Guardian
________________________, 2012
(Date)