OPC Participant Medical Report
Participants Full Name: _________________________________________________ Date: ____/____/_____
OPC Activity participating in:_________________________________________ Date of Trip: ___/___/_____
Physician has read trip description for physical demand of participant. YES / NO
Do you have any medical condition that would limit your participation on this trip that we should be aware of?
NO / YES
If YES, please elaborate on any precautions, if any, apply or should be taken during the trip?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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**Physician’s Report: Although a physician’s approval to participate in this course is not required, if you have any questions
regarding your fitness to participate in physically and mentally challenging activities you should contact your physician and
seek their advice. The Miami University outdoor staff would be happy to answer any questions your physician may have in
regard to specific activities you may participate in. If you have any of the following conditions, you should contact your
physician: High blood pressure, Diabetes, seizure disorder, chest pain, shortness of breathe, palpitations, sweats, or weak
spells, smoke more than one pack of cigarettes a day or have at least one other risk factor on this list, current or prior
cardiovascular disease, overweight or obese, long term sedentary lifestyle.
OPC Consent to Medical Treatment
I, _______________________________________, hereby authorize any duly authorized doctor, emergency medical
technical hospital or other medical facility to treat me for the purpose of attempting to treat or relieve any injuries I may have
incurred as a participant with the Miami Outdoor Pursuit Center.
I consent to the administration of anesthesia as deemed advisable by any licensed physician. I realize and appreciate that
there is a possibility of complications and unforeseen consequences in any medical treatment, and I assume such risk.
________________________________________
______/_______/_______
Participants Signature
Date
________________________________________
______/_______/_______
Parent’s Signature
Date
Emergency Contact Information
Name:__________________________________
Relation:________________________
Home Phone:____________________________
Cell Phone:_____________________
Outdoor Pursuit Center
Photographic, Audio, and Video Graphic Release
I, __________________________________, hereby give the Outdoor Pursuit Center at Miami University the right and
permission to use, reuse, and/or publish photographic, audio, and video graphic materials of me while participating in one of the
Outdoor Pursuit Center’s trips, workshops, climbing wall, or any other activity related to the Outdoor Pursuit Center. I do
hereby waive the right to inspect and/or approve the photograph, audio tape, and/or videotape. I further agree that those who act
in behalf of the Outdoor Pursuit Center may transfer, use or cause to be used, these photographs, audio tapes, and/or videotapes
for promotional, recruiting, or educational purposes, without any limitation, reservation, or compensation, other than the receipt
of which is hereby given. This consent is given for any photographs, audio tapes, and/or videotapes which have been taken,
about to be taken, or will be taken.
Participant Signature: _____________________________________________
Witness Signature: _______________________________________________
Date: ____________