BAY KAYAKING MEDICAL AWARENESS FORM
Prior conditioning is strongly recommended. Clients are expected to take personal responsibility for their own safety. Please consider the above statements carefully as you complete this form.
NAME:
_____________________________________________________________________
PHONE: _______________________________________AGE:
________________________
WHO TO CONTACT IN AN EMERGENCY:
Name:_________________________________________ Phone: _______________________
Physician’s Name: _______________________________ Phone: _______________________
Medical Insurance Company: _____________________________________________________
Do you have a history of or currently
have:
Yes
No
1.
Cardiac problems? __________________________________________________________
2.
Respiratory problems or Asthma? _____________________________________________
3.
Diabetes of Blood Sugar problems? ____________________________________________
4.
Epilepsy or Seizures? _______________________________________________________
5.
Mental or Neurological Problems? _____________________________________________
6.
Bleeding disorders or Immune Deficiencies? _____________________________________
7.
Musculoskeletal Injuries (breaks, sprains, dislocations)? _____________________________
8:
Allergies to medication? (Specify) _____________________________________________
9.
Allergies to food, plants, insects? (Specify) ______________________________________
10. Currently taking medication (Specify)
__________________________________________
11. Any other issues or conditions that
may affect
your ability to participate? (Specify)
______________________________________________
I understand and acknowledge Bay Kayaking
is not making a determination of my fitness for any outing; rather, I represent Bay Kayaking and verify that I am physically
fit and ready for any outing I participate in. (Initial) ______________________
I understand and acknowledge that my failure
to disclose relevant information may result in harm to others and myself during an outing.
I represent and warrant that I have provided all material and important information to Bay Kayaking pertaining to my
medical, mental and physical condition in view of my participation. I agree to
notify the Bay Kayaking staff if there is any change in my mental, physical or medical condition prior to or during any activity.
(Initial) ____________________
Consent for Medical Treatment
I certify all the above is accurate and
consent to any emergency, first aid or medical treatment, which may become necessary during or in connection with my participation
in any Bay Kayaking activity.
(Sign) ___________________________________________ (Date) _____________________
