HEALTH INFO

Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Gender *

Please select one. This information is for medical purposes only in case of emergency.

Male

Female

Other

Prefer not to answer

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Guardian Phone

(###)

###

####

Physician Phone

(###)

###

####

Policy Holder Date of Birth

MM

DD

YYYY

Prescribing Physician Phone

(###)

###

####

Prescribing Physician Phone

(###)

###

####

Select all that apply *

Hay Fever

Poison Ivy/Oak

Insect Stings

Food

Penicillin

Other Drugs

Other

None

Health History

Please provide the following info by checking all that apply regarding a history of or is prone to any of the following

Recent injury, illness, or infectious disease

Chronic or recurring illness

Asthma

Seizure Disorder

Dizziness during or after exercise

Chest pain during or after exercise

Heart Defect/Disease

Hypertension

Bleeding/Clotting Disorders

Diabetes

Mononucleosis (in last 12 months)

Chicken Pox

Measles

Mumps

Tuberculosis

Hepatitis

Joint problems

Fractures

Frequent Headaches

Head Injury

Eating Disorder

Diarrhea or constipation

Frequent Stomach Aches

Wears glasses or contacts

Been hospitalized (within last 12 months)

Wears a Medic Alert ID

Date of Last Physical Exam

MM

DD

YYYY

Authorization

My attendee has permission to engage in all prescribed Woodshed Experience activities except as noted. The information provided on this form is accurate to the best of my knowledge. I have indicated any special health conditions, including required medication and activity limitations which should be known to the staff and medical personnel. I am aware of and accept the risk inherent in the program activity. I give consent in advance for medical treatment at an appropriate facility in case of illness or injury. I hold harmless any and all Woodshed Experience staff. By checking the box below, I consent to the above statements.

I agree