Medical History, Treatment Permission and
Informed Consent, Permission, Release & Assumption of Risk for Participants
This is a required form for all participants. Please print legibly.
Participant Information
Name
First
Middle
Last
Age __________ Date of Birth ______________________
Home Address ________________________________________________________________________
Street Address
City
State
Zip
Code
Emergency Contacts and Persons Authorized to Pick up Participant
Parent or Guardian Information
Father/Guardian Name _________________________________________________________________
First
Middle
Last
Home Address ________________________________________________________________________
Street Address
City
Cell
State
Zip Code
Phone: Home
Work
Pager
Mother/Guardian Name ________________________________________________________________
First
Middle
Last
Home Address ________________________________________________________________________
Street Address
Phone: Home
City
Work
State
Pager
Cell
Zip Code
Other Contact Person Name
First
Middle
Last
Home Address ________________________________________________________________________
Street Address
Phone: Home
City
Work
Cell
State
Pager
Zip Code
Medical Information
Family Physician_____________________________________________ Phone___________________
Medical History (If necessary, use back of this sheet)
Date of Last Tetanus Booster_____________
Allergies: Insect bites/stings____________________________________________________________
Food_______________________________________________________________________
Drug_______________________________________________________________________
Other______________________________________________________________________
Is participant under the care of a provider for either medical or psychological reasons? Yes___No___
If yes, please explain __________________________________________________________________
____________________________________________________________________________________
Is participant taking medically prescribed medication? Yes___No___If yes, please explain ___________
____________________________________________________________________________________
Other information of which we should be aware? ____________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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1. Participant wishes to participate in UCCS Activities. Participant understands that risks and dangers in the Activities
include but are not limited to falls, falling objects and broken or improperly used equipment, which could result in
damage to or loss of property, drowning, illness or disease, physical or mental injury or death of participant or other
persons. Injuries that may result from participation in these Activities may include, but are not limited to, cuts, bruises,
or sprained joints, broken bones, psychological trauma, infection, and death. Participant freely participates in the
Activities. Participant understands and assumes all associated risks of personal injury or loss, bodily injury (including
death), damage to, loss, or destruction of any personal property occurring in connection with or arising out of
participation in the Activities.
2. Participant states to the best of his or her knowledge that Participant is free from any known health condition that
could hinder or prevent active participation in or otherwise jeopardize the well-being of others in the Activities. By
his/her signature below, Participant affirms that Participant is in good health and that participation in the camp will in
no way aggravate such health condition. Participant will seek medical advice as appropriate.
In the event of an emergency, Participant grants the University of Colorado permission to authorize emergency
medical treatment for [himself/herself] for the duration of [his/her] participation in these Activities:
Health/Medical Insurance Company__________________________________ Policy #:_____________________
Emergency Contact: Name: ________________________________________ Phone: ______________________
Participant understands that University of Colorado does not carry or provide health or accident insurance that
responds to injury or illness as a result of his/her participation in these Activities.
3. Participant agrees to, and understands the importance of, following rules and regulations as set forth by
camp leaders to minimize risk to Participant and others. Participant will neither bring nor possess any items, such
as knives, weapons, and illegal drugs, or other items which might endanger Participant or others. Possessing the
above may result in removal from the Activities.
4. Participants in University of Colorado events are sometimes photographed and videotaped for use in
promotional and education materials. Participant understands that such audio, video, film and/or print images
may be edited, duplicated, distributed, reproduced, broadcast, and/or reformatted any form and manner without
payment of fees. Participant authorizes the University of Colorado to record and photograph Participant’s image
for use by the University of Colorado or its assignees in research, educational and promotional programs.
5. Participant hereby releases and discharges, indemnifies and holds harmless The Regents of the University of
Colorado, a body corporate, and its member 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, costs and expenses, and causes of action whatsoever, either in law or equity, arising out of or
in any way connected with any loss and/or bodily injury and/or disability, arising from Participant’s participation
in the Activities.
Having had sufficient time to review and seek explanation of the provisions contained above, Participant
voluntarily gives consent and agrees to this Informed Consent, Permission, Release and Assumption of Risk.
This 2-page document is not valid if either page is missing.
Participant’s name (Print)
Participant’s signature
Date
If participant 18 or over
If Participant is under 18 years of age
Parent(s) or Legal Guardian(s) Name (Print)
Parent(s) or Legal Guardian(s) Signature
Date
Parent(s) or Legal Guardian(s) Name (Print)
Parent(s) or Legal Guardian(s) Signature
Date
This form is valid for one year from the date of signature.
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