MEDICAL INFORMATION FORM

HIGH SCHOOL HIKERS

SIERRA CLUB, HAWAII CHAPTER

 

Name: __________________________________ Social Security #: _______________ Address:________________________________________________________________

City, State: ___________________________________________ Zip: _____________ Phone: _______________________ Gender: _________ Birth Date: ______________ Height: _________________ Hair Color: ____________ Eye Color: ______________ Allergies: _______________________________________________________________ Recent Illness: ___________________________________________________________ Operations, Serious Accidents: ______________________________________________ Current Medications: _____________________________________________________

Please note if you have had an occurrence of any of the following. If you checked YES for any of the below, please explain present condition on a separate sheet.

Asthma ___ ___ Diabetes ___ ___

Heart disorder ___ ___ Anemia ___ ___

Mental illness ___ ___ Epilepsy ___ ___

Other lung disorders ___ ___ Pneumonia ___ ___

Other medical disorders ___ ___ Tuberculosis ___ ___

Ability to do moderately strenuous physical work: YES NO

Do you have an unreasonable or undue fear of heights or exposed places: YES NO

Are you allergic to any medication, or suffer from harmful side effects with particular medications: YES NO

If YES, please indicate which medication(s): ___________________________________ ________________________________________________________________________

 

MEDICAL INFORMATION FORM

HIGH SCHOOL HIKERS

SIERRA CLUB, HAWAII CHAPTER

Page 2

Full Name of Parent(s) or Guardian(s): _______________________________________ Address (include city, state, zip) or Parent(s) or Guardian(s) if different from page 1: ________________________________________________________________________ Daytime Phone: ______________________ Evening Phone: _____________________ Pager #: ____________________________ Cellular Phone: _____________________

NOTICE: The following is required. Participants will not be accepted without it.

Is participant covered by medical insurance? YES NO

If YES, insurance provider and policy #: ______________________________________ Name of Physician: ___________________________ Phone: ____________________ Name of Preferred Hospital: ________________________________________________ Date of last tetanus shot: ___________________________________________________ If not within ten years, a booster should be obtained before participating at camp.

TO THE BEST OF MY KNOWLEDGE, ALL INFORMATION ON THIS FORM IS CORRECT AND CURRENT. I AUTHORIZE THE TRIP LEADER(S) TO GIVE OR ARRANGE FOR ALL NECESSARY MEDICAL CARE FOR THE PARTICIPANTS IN CASE OF ILLNESS OR INJURY WHILE ON THE TRIP. I UNDERSTAND THAT MEDICAL EXPENSES INCURRED DURING THE TRIP ARE THE RESPONSISBILITY OF THE PARTICIPANT. IN SIGNING BELOW, I ACKNOWLEDGE ON BEHALF OF THE PARTICIPANT AND/OR THEIR GUARDIAN THAT I UNDERSTAND AND WILL COMPLY WITH THE ABOVE STATEMENTS.

Signature of Participant: _______________________________

Date: _________________

Signature of Parent/Guardian: ____________________________

Date: __________________

Signature of Parent/Guardian: ____________________________

Date: __________________

*Advisors: Make a copy and turn in with your other student forms.