Health History & Examination Form

CHALLENGER WEST 2018

Health and InsuranceForm

Sponsoredby:

UnitedChurchofGod,anInternationalAssociation

PERSONALINFORMATION(Pleasetype or print clearlyinallsections)

Applicant'sName: Sex: Male FemaleBirthDate:/ / .

FirstM.I.Last

Address: Phone:( )

StreetAddressCityStateZip

SocialSecurityNumberofParticipant: - -

Parent/GuardianorEmergencyContact: Relationship:

Telephone: ( ) ( ) ( )

HomeWorkOther

SecondParent/Guardian/EmergencyContact: Relationship:

Telephone: ( ) ( ) ( )

HomeWorkOther

MEDICAL/HEALTHHISTORY

HealthHistory– Explainany“yes”answersbelow

Does/did theparticipant have:YESNOYESNO

1. Recent injury, illness or infectious disease?......

2. Mononucleosis in the past 12 months?......

3. Chronic or recurring illness/condition?......

4. Diabetes?......

5. Food allergies?......

6. Allergic to any medications (list below)......

7. Respiratory problems or asthma?......

8. Frequent headaches, or migraines?......

9. Ever passed outduring or after exercise?......

10.Ever been dizzyor faint during or after exercise?.

11.Ever experienced altitude symptoms?......

12.Ever had seizures?......

13.Ever had chestpain during or after exercise?......

14.Heart murmur?......

15.High blood pressure?......

16.Deep vein thrombosis?......

17.Blood disorder?......

18.Back injuries or problems?......

19.Joint injuries?......

20.Sleepwalking?......

21.Eating disorder?......

22.Overweight or underweight?......

23.Emotional or mental difficulties for which

professional help was sought?......

24.(Females): Treatment for menstrual cramps?......

25.(Females): Pregnant?......

Ifyouchecked“yes”to anyof theabove, please notethe question# and explain,includinganycontinuingmedicationsneeded.

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Pleaselistallmedications(including over-the-counter orother nonprescriptiondrugs)taken routinely. Besureto bringyourmedicationwith you in the original packagingthat willidentify thedoctor, thedosageandthefrequency ofadministration:

Doyouhaveanyhealthissuesthatmighthinderyoufromparticipatingfullyintheprogramasdescribed? Yes No

Ifyes,pleasedescribeindetail(attachnoteifnecessary):

Whichofthe followinghastheapplicanthad? (Checkeachonethat applies)

Measles ChickenPox GermanMeasles Mumps Rheumatic Fever

HepatitisA HepatitisB HepatitisC TBTest(Date: ,PosorNeg? )

Immunizations–Fillin thedatesforanyofthefollowingimmunizationsapplicanthashad.

NOTE: A record of immunizations is for informational purposes.Immunizationsare not a required prerequisite for acceptance orattendance. Ifa participant has not been immunized, however, and one of the above-namedcommunicable or contagious diseases is found in the group, he orshe will be subject tothe regular quarantine or isolation procedures ofthe program and of the community for persons who are not immune.

ADULTAPPLICANT:I certifythattothebestofmyknowledge thatthishealthhistoryisaccurateandcomplete,thatIamin goodhealthandabletoparticipatein thisprogram.

Adultapplicantsignature: Date

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INSURANCECOVERAGEANDRELEASE

InsuranceCompany: PolicyorGroup# SocialSecurity NumberofPolicyholderorInsuranceIDNumber: PolicyholderDateofBirth: InsurancePhone# ( ) Address: Family Physician: Phone:( ) Address: FamilyDentist/Orthodontist: Phone: ( )

Address:

PersonalMedicalInsurance

WhileweplaceasignificantemphasisonsafetyattheChallenger Westprograms,accidentsmayhappenandpeoplemaygetinjured.Forthisreason,westronglyrecommendthatyoucarryadequatepersonalmedicalinsurance.Werealizethatitisnotalwaysaffordable. However,payingactualhospitalanddoctorexpensescaneasilycostfarmore.Aswereviewyourapplication,thisisanimportantfactorindeterminingthosemostsuitedtoparticipate inthe program.

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SupplementalAccidentInsurance

Werealizethatyourpersonalinsurancemayrequireyoutopayadeductibleandco-payments,andpossiblyother costs.Inanefforttohelpreducethecosttoyoupersonally,theChurchhasbeenabletoacquiresupplementalaccidentmedicalcoverageforanominalcost.ThoughtheChurchisunabletoprovidefinancialassistancebeyondwhatisofferedthroughthisinsurance,wearehappytoincludeallprogramparticipantsinthiscoverage.Theextent(amountandperiod)ofaccidentcoveragemayvaryfromyeartoyear. Ifyouareacceptedtothisprogram,a copyofthecoveragewillbesupplieduponrequest.

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ReleaseandWaiver

I haveread,fullyunderstand,andagreetocomply withalltherulesandstandardsoftheproject anditsstaff. I understand andagreewithitsimplicationsandthestatedconsequences.Ialsoaffirmthattheinformationgiventhis applicationistrueandcompleteandthatIamingoodhealthandabletoparticipateintheexpectedactivities androutinefortheproject(s)markedonthefront.Inconsiderationofbeingallowedtoparticipate,Ihereby release,indemnify,saveandholdharmlessandcovenantnottosuetheUnited Church ofGod,anInternationalAssociation,itsofficers,CouncilofElders,agents,employees,volunteersandhelpersandanyotherrelatedentity(hereinaftercollectivelycalledthe“Church”)fromallactions,claims,demandsorsuitswhicharebasedupon,orresultfrominjuriessustained,arisingoutof,orinthecourseof,participationorattendance at camp. This release,however,shall not apply to claimscoveredby the Church’s liability insurance(e.g.foritsnegligence),butisapplicabletoclaimsnot coveredbythatinsurance.Itisstronglyrecommendedthat you have yourownmedicalinsuranceprotectionsinceparticipantsareinvolvedinactivitiesattheirownrisk.

Signature

DateSigned

PrintName_

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MEDICALEXAM/RECOMMENDATIONANDRESTRICTIONS

Anexambyamedicalpractitioneristobedonewithin12monthsofparticipationintheprogram. Usetheformbeloworattacha similarpractitioner’sexamform.Submityourmostcurrentexamformforeachprogramsession.

Applicant’sName: BirthDate: / /

Ihaveexaminedtheabovenamed participant on / / (date).BPWeight Height In myopinion,theaboveapplicant: is isnotabletoparticipateinanactiveoutdoorwilderness/adventureprogram that involves strenuous physical activity (backpacking, rock-climbing) in altitudes of 10,000+ feet.

Theapplicantisunderthecareofaphysicianforthefollowingconditions

Currenttreatmentatthetimeofthisreportincludes

RecommendationsandRestrictionsfortheChallengerWestProgram

Treatmenttobecontinuedatcamp

Medicationstobeadministeredattheprogram(name,dosage,frequency)

Anymedically-prescribedmealplanordietaryrestrictions

Knownallergies

Descriptionofanylimitationorrestrictiononprogramactivities

Additionalinformationforhealthcarestaffattheprogram(use reverse side if necessary):

SignatureofLicensed MedicalPersonnel Printedname Title Address

Phone Date

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