Glendale Outdoor Leadership School Health History Form:

                                                                
Name __________________________________________________________________
                        Last                                         First                                     Middle
Home address____________________________________________________________
                                Street address                 City                                 State                 Zip

Gender: Male____ Female____ Birth date____/____/____ Age____

Custodial parent/guardian___________________________________________________
                                                            Name
Home address (if different from above)______________________________________________________________________
                                                                    Street address                             City                                         State                   Zip

Home phone (    ) ____________________ Work phone (    ) _____________________ Cell phone (    ) _________________

Second parent or emergency contact__________________________________________

Home address_________________________________________________________________________________
                            Street address                                                 City                                         State                 Zip

Home phone (    ) ___________________Work phone (    )______________________Cell phone (    ) _________________

Relationship ______________________________________________________

Emergency Contact (Please list 2 other contacts if the above Persons are not available)

Name ____________________________________________________Phone # ___________________________________

Name ____________________________________________________Phone # ___________________________________

Insurance Information: Is the participant covered by family/hospital insurance? Yes ____ No ____

If so, indicate carrier or plan name ________________________________________group # _________________________

Insurance carrier address ______________________________________________Phone number ____________________

Name of physician ___________________________________________________ Phone number ___________________

Allergies

To medication_______________________________________________________________________________________

Seasonal ____ Bee stings ____ Asthma ____ Food _______________

Other___________________________________________

Current Medications, including dosage ______________________________________________________________________

Does not eat: Red meat ____ Pork ____ Dairy products ____Poultry ____Seafood ____Eggs ____ Other_________

Medications Being Taken:
Please list ALL medications (including over-the-counter or nonprescription drugs) taken routinely. Bring enough medication to last the entire time of this event. Keep it in the original packaging bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage and the frequency of administration.

 ____ This person takes NO medication on a routine basis OR ____ This person takes medication as follows:

Med #1 _____________________ Dosage _______Specific times taken each day _________Reason for taking___________ Med #2 _____________________ Dosage ______  Specific times taken each day _________Reason for taking___________ Med #3 _____________________ Dosage _______Specific times taken each day _________Reason for taking___________

Health History General Question: (Check “yes” answers and explain below)

Has/does the participant:

Had any recent injury, illness, or infectious disease?____
Ever had back problems? ____
Have a chronic or recurring illness/condition? ____
Ever had problems with joints (e.g. knees, ankles)? ____
Ever been hospitalized? ____
Have an orthodontic appliance being brought to the event? ____
Ever had surgery? ____
Have any skin problems ____
Have frequent headaches? ____
Have diabetes? ____
Ever had a head injury? ____
Have asthma? ____
Ever been knocked unconscious? ____
Ever had an eating disorder? ____
Wear glasses, contacts, or protective eye wear? ____
 Had a problem with diarrhea/constipation? ____
Ever passed out during or after exercise? ____
Ever had seizures? ____
Ever been dizzy during or after exercise? ____
Ever had high blood pressure? ____
Ever had chest pain during or after exercise? ____
Ever been diagnosed with a heart murmur? ____
Other? ____

Please explain any yes answers. ________________________________________________________________________________________________________________________________________________________________________________________________________________________

Use this space to provide any additional information about the participant’s behavioral, physical, emotional, or mental health. ____________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________

Describe your current fitness and physical activity levels. ________________________________________________________________________________________________________________________________________________________________________________________________________________________


I certify that the above information is complete and accurate to the best of my knowledge. I herby state that _________________________ is capable of safely participating in activities offered through Glendale Outdoor Leadership School.
Name of Participant
I understand that there is inherent risk with participation; including serious injury and/or death. If any of the above stated information changes, I will inform GOLS.

 ____________________________________________________________
Print name                                             Signature (participant or guardian) Date