Kent Mountain Adventure Center, Inc.

                                                                 P.O. Box 835

                                                           Estes Park, CO  80517

                                                                (970) 586-5990

                                                        Participant Medical Form

COMPLETED FORM IS REQUIRED

Participant Name: ___________________________________   Age: ____   Date of birth: ______/_____/_____

Address/P.O. Box: _____________________________________________________________________________

City: _____________________________________________________   State: ___________   ZIP: ____________

Name of Course:  Environmental Education in the Rockies  NRRT 365

M _____    F _____     Height:  ___________  Weight: _____________  Last physical exam: _____/_____/_____

Dates of immunizations:  Tetanus: _______________   Polio: ________________   Measles: ________________

Please include a copy of the participant's latest medical physical including immunizations.

Emergency Contact Name:  ______________________________________Relation:  _______________________

Day phone: (________)______________________________   Night phone: (________)_____________________

If above party cannot be reached, please contact:   (list two individuals):

1.  Name: _____________________________ Relationship to participant____________________________           

Phone:  _______________________________        Alternate Phone:_____________________________________

2.  Name: ____________________________   Relationship to participant _______________________________

Phone: _______________________________         Alternate Phone: ______________________________________

List any chemical or drug allergies (penicillin, sulpha, iodine, etc.): ____________________________________________

______________________________________________________________________________________________________

List any allergies: food (nuts, fish, peanut butter, dairy, etc.), insects (bee stings, etc.), hayfever (pollen, mold, etc.): ______________________________________________________________________________________________________

______________________________________________________________________________________________________

Has participant ever been stung by a bee/wasp:    Yes       No 

Has participant experienced any dizziness, fainting, epilepsy, asthma, sleep walking: 

The following may be given if deemed necessary to relieve minor pain and discomfort:

Tylenol                                  Yes   No                      Ibuprofen                            Yes   No

Immodium for diarrhea              Yes   No                      ExLax for constipation            Yes   No

Decongestant                         Yes   No                      Antihistamine                        Yes   No

Antacid for indigestion              Yes   No                      Throat lozenges                    Yes   No

continued

List all medications participant is currently taking:

Name of med.: ______________________________    Name of med.: ____________________________________

Dosage: __________________________________      Dosage: __________________________________________

Times given: ______________________________      Times given: ______________________________________

Date medication started: ____________________      Date medication started: ____________________________

Reason for medication: _____________________       Reason for medication: _____________________________

Special diet?: _________________________________________________________________________________

Does the participant have any pre-existing medical conditions?:  ______________________________________

_____________________________________________________________________________________________

Past history of injuries (include dates): ___________________________________________________________

_____________________________________________________________________________________________

Additional comments (use a separate sheet if necessary): ____________________________________________

I hereby give my permission to the physician selected to hospitalize and secure proper treatment for me including emergency care.

Signature of participant:

_____________________________________________________Date:___________________

Signature of parent/guardian (if under 18):

______________________________________________________Date:_____________

Participant's Doctor: ____________________________________ Phone: (_______)___________________

Doctor's address: _____________________________________________________________________________________

Medical Health Insurance: Company:

____________________________________________________________________

Address:

____________________________________________________________________________________________

Policy #: ___________________________  Group #: ____________________ 

Phone:(_______)____________________

If there are any changes in the participant's medical status between now and the course beginning date, please contact KMAC with the new information as soon as possible (970) 586-5990.

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