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

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

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

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

Emergency Contact Name: Parent/Guardian: _______________________________________________________

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

If parents/guardian cannot be contacted, please contact (list two individuals):

1.  Name: _______________________________________              2. Name:______________________________

Relationship to participant: ________________________                Relationship to participant: ______________

Home phone: (________)__________________________                Home phone: (________)________________

Business phone: (________)_______________________                 Business 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

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): ____________________________________________

In case of an emergency, every effort will be made to contact my parent or legal guardian.  In the event my parent or guardian cannot be reached, I hereby give my permission to the physician selected to hospitalize and secure proper treatment (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 departure, please contact KMAC with the new information as soon as possible (970) 586-5990. Email:  kmac@frii.com