LONGWOOD UNIVERSITY
DEPARTMENT OF CAMPUS RECREATION
Longwood Outdoor Club
Health Statement
This health statement will be reviewed by the trip's leaders. It is designed to give the trip leaders a better understanding of who you
are so that they can better prepare for, and serve your individual needs. In the event of injury, this statement will be shared with
emergency medical personnel and 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:
Medical Insurance Co.:
Email: ____________________________________
Height:
Weight:
Birth date:
Medical Insurance Policy #:
In Case of Emergency, Please Contact:
Name:
Address:
City, State, Zip:
Doctor’s Name:
Relationship:
Day Phone:
Evening Phone:
Dr.’s Phone:
First Aid Certification:
CPR Certification:
Swimming Ability:
Do you wear glasses?
Expire Date:
Expire Date:
Do you smoke?
Do you wear contacts?
Health History:
Allergies: (e.g. wasp/bee or other insect stings, prescription or non-prescription drugs, foods, etc.)
Penicillin
Yes No
Reaction
Sulfa products
Yes No
Reaction
Iodine
Yes No
Reaction
Food
Yes No
Reaction
list:
Stings/bites
Yes No
Reaction
list:
Other Allergies Yes No
Reaction
list:
____________________________________
Do you carry an EpiPen or other treatment for Anaphylaxis?
Yes No
Do you carry an inhaler or other treatment for Asthma?
Yes No
What is your blood type?
When was your last tetanus shot?
Please list any current medications that you are taking. ________ None
Medication
1.
2.
3.
4.
Condition
Dosage (amount / frequency)
Side Effects
Conditions requiring ongoing medical attention (e.g. asthma, diabetes, headaches, back injuries, dislocations,
knees, etc.) that may or may not affect your performance on this trip? ________ None. If yes, please describe:
Do you have a history of heart problems (e.g. shortness of breath, heart palpitation, exertional dizziness, sweats,
faint spells? ________ None. If yes, please describe:
Do you have any disabilities? Fears or phobias? ________ None
What is your current level of fitness - daily exercise plan?
Is there any other information that we should know about?
I have verified with my physician and other medical professionals that I have no past or current physical or
psychological condition that might affect my participation on the trip, other than described on this form. I
authorize the Longwood Outdoor Club to obtain or provide emergency hospitalization, surgical or other medical
care for my health and safety. I understand that the expense of this service will be my responsibility. I certify
that this form is a complete and accurate statement of my health.
Trip Name:___________________
Signature of Participant (1st Trip):
Date:
Please review information above prior to signing for additional trips.
Trip Name:___________________
Signature of Participant (2nd Trip):
Date:
Trip Name:___________________
Signature of Participant (3rd Trip):
Date:
Parent or Guardian Signature
(Must Be Completed For Participants Under 18 Years of Age)
I have verified with our physician and other medical professionals that my participant has no past or current
physical or psychological condition that might affect participation on the trip, other than described on this form.
I authorize the Longwood Outdoor Club to obtain or provide emergency hospitalization, surgical or other
medical care for my participant’s health and safety. I understand that the expense of this service will be solely
my responsibility. I certify that this form is a complete and accurate statement of my participant’s health.
Signature of Parent if participant is under 18 years old:
Date: