Participant Health History Form for Adventure / Challenge Activities

Battle Creek Public Schools Outdoor Education Center, Clear Lake Camp
10160 S M-37 Hwy, Dowling, MI 49050. PH: 269-721-8161. www.clearlakecamp.org

PLEASE READ: This information is used to make facilitators of participant’s medical conditions, allergies, or other information which should be taken into consideration when leading activities or in case of an emergency situation. If participant is a minor, please answer these questions as they relate to the participant.

Participant’s Name Participant’s Name * First Last
Name of School (if applicable)
Grade (if applicable)
Parent/Guardian’s name (if participant is a minor) Parent/Guardian’s name (if participant is a minor) First Last
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone * - ### - ### ####
Participant’s Birth Date Participant’s Birth Date * / MM / DD YYYY
Emergency Contact #1 Emergency Contact #1 * First Last
Phone Number for Emergency Contact #1 Phone Number for Emergency Contact #1 * - ### - ### ####
Emergency Contact #2 Emergency Contact #2 * First Last
Phone Number for Emergency Contact #2 Phone Number for Emergency Contact #2 * - ### - ### ####
1. Do you have any preexisting injuries (ankles, knee, back, neck, etc,)? *

1. Do you have any preexisting injuries (ankles, knee, back, neck, etc,)? YES NO
If so please explain
2. Are you currently taking any medications? *

2. Are you currently taking any medications? YES NO
If so please list
3. Do you have a history of heart problems or are you taking heart medication? *

3. Do you have a history of heart problems or are you taking heart medication? YES NO
If so please explain
4. Do you have high blood pressure or a history of high blood pressure? *

4. Do you have high blood pressure or a history of high blood pressure? YES NO
5. Do you have any allergies? (food, bees, insects, medications, etc.) *

5. Do you have any allergies? (food, bees, insects, medications, etc.) YES NO
Are you carrying an epi-pen or other allergy medication today?

Are you carrying an epi-pen or other allergy medication today? YES NO
Please list allergens
6. Do you have asthma? *

6. Do you have asthma? YES NO
Are you carrying an inhaler with you today?

Are you carrying an inhaler with you today? YES NO
7. Do you have diabetes? *

7. Do you have diabetes? YES NO
If yes, what medications or other management tools do you have with you today? Please explain.
8. Do you have any other physical limitations? *

8. Do you have any other physical limitations? YES NO
If so please explain
9. Current level of activity at home. *

9. Current level of activity at home. LOW MEDIUM HIGH
Please include any additional information our facilitators should know.
Participant signature. Draw your signature into the box below. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Today’s Date Today’s Date * / MM / DD YYYY
Parent/Guardian signature (if participant is a minor). Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.