VENTURE OUT MEDICAL HISTORY FORMPlease Print – Fill out both front & back

 Name: Today’sDate:

First Middle Initial Last

Address:

City: State: _ZipCode:

Telephone:Home:( ) Work:( )

NameofPersonalPhysician: Phone:( )

EmergencyContact: Relation:

Phone: Address:

HealthInsuranceCompany:

HealthInsurancePhoneNumber: ( ) PolicyNumber:

DateofBirth: Age: Height: Weight:

Listanyspecialdietconsiderations:

MEDICAL HISTORYPlease describe condition/treatment where possible.

 1. Areyoucurrentlyundertreatmentforanyillnessorcondition?

Describe: 2. Doyouhaveaconditionthatrequiresregularmedication?(E.g.diabetes,epilepsy,asthma,

etc.)Describe: 3. *Areyoucurrentlytakingover‐the‐counterorprescriptionmedication?(Ifyes,explainwhat

eachmedicationistakenfor) List:

4. Hasyourdoctororothermedicalprofessionaltoldyoutolimityouractivityinanyway?Describe:

5. *Haveyoubeendirectedtocarryaninhalerorotherbreathingdevice?(Ifyes,whyandhowoftenisitused?)

6. Haveyoueverhadordoyoucurrentlyhaveanyallergies?List:

7. Haveyoueverhadanallergicreactiontoinsectstings?Describereaction:

8. *Doyoucarryepinephrine?(e.g.“EpiPen”)9. Couldyoubepregnantorareyouattemptingtobecomepregnant?(ifpregnant,beawarethat

climbingharnessescancausepotentialproblems)10. Doyouhaveanyphysicallimitationswhichcouldimpactyourparticipationinthisactivity?

Describe: 11. Haveyoueverhadinjuriesincludingback,spine,brokenbones,sprains,dislocations,soft

tissueinjury?Listinjury,yearofoccurrence,andcurrentcondition:

12. Haveyoueverundergonesurgery?Ifyes,explain: 13.   Describeyourswimmingability/comfortinwateronascaleof0‐3 (0: cannot swim, 1: can float   

2: basic paddle/stroke, 3: very comfortable)  14.Dateoflasttetanusshot:

*YouarerequiredtohavethesewithyouduringVentureOutactivities

CARDIAC RISK FACTORSNOTE: Research has demonstrated that adventure activities can raise heart and respiration rates in any participant and the persons with heart and respiratory problem histories can be placed at extreme risk. Individuals with 3 or more cardiac risk factors may be at  risk.

1. Doyouexerciselessthanonceaweek?2. Doyou(oranyoneinyourgeneticfamily)haveahistoryofheartproblems?(I.e.highcholesterol,

heartmurmur,elevatedbloodpressure,heartattack,surgery,etc.)Describeindicatewhom:

3. Doyougetsqueezingtightnessorpressureinyourchestduringexercise?Describe:

4. Doyouusetobaccoinanyform?(cigarettes,snuff,etc.)5. Doyouhave3ormoreofthefollowingCardiacRiskFactors?Circle which apply. (Age–males:>45,

females:>55;tobaccouse;familyhistoryofheartdisease;highbloodpressure;elevatedcholesterol;diabetes).Ifyouhave3ormorecardiacriskfactors,consultwithyourphysicianandobtainwrittenapprovalfromthemtoparticipateinVentureOutactivities.WithoutwrittenapprovalfromyourphysicalortheStudentHealthCenter,youmaybeaskedtolimityourparticipationinsomeactivities.

ListanyotherhealthconcernsyoufeelthattheVentureOutstaffshouldbeawareofbeforeyouparticipateinouractivities:

Comments:

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FOR OFFICE USE ONLY

142McComasHall895WashingtonSt.SWBlacksburg,VA24061

540.231.4982ventureout@vt.edu

VENTURE OUTAssumption of Risk Form

(PleasePrint)I, ,wishtoparticipateinrecreationalactivitiesofferedthroughVentureOut,aprogramofTheDivisionofStudentAffairs(Dept.ofRecreationalSports).Indoingso,Iagreetoindemnify,defend,andholdharmless,VirginiaPolytechnicInstituteandStateUniversityandtheirofficers,agents,andemployeesfromanyclaims,damages,andactionsofanykindornature,whetheratlaworinequity,arisingfrommyparticipationinaVentureOuttrip,providedthatsuchliabilityisnotattributedtothesolenegligenceoftheUniversity.

IunderstandthatbyparticipatinginaVentureOutactivityIamexposingmyselftomanypotentialhazards,includingbutnotlimitedto,severeinjuryand/ordeath.TheVentureOutstaffstrivestomanagetheserisks,butmanyrisksarebeyondthecontroloftheVentureOutcenterstaff.ThefollowingarealistofsomeinherentdangersandrisksthatmayormaynotbepresentonaVentureOuttrip:

Injury,illness,and/oranyotherincidentsthatmaytakeplaceaconsiderabledistancefrom911emergencysystemswithlimited

cellphonecoverage. Travel in a vehicledrivenby someoneother thanmyself Forcesofnatureincludingstorms,lightning,wind,rain,snow,ice,cold,heat,changesinweather,andwaterlevels Injuriestoorgans,muscles,joints,andbones Injuriesinflictedbyanimals,plants,UV‐‐‐rays,and/orothernaturalcauses Physical exertion associated with outdoor adventure related activities (fatigue,muscle soreness, joint stiffness, and blisters) Exposuretofire(man‐‐‐madeornatural) Hazardsassociatedwithwater Potentialhazardsassociatedwithbackcountry navigation Problemsresultingfromimproperuseofequipment

IwillinglychoosetoparticipateintheVentureOutProgram.Whileparticipating,Iwillberesponsibleformyequipmentandmyself.IunderstandthatVirginiaTechdoesnotcarrymedicalinsuranceforparticipantsinvolvedwithVentureOutandthereforeIamresponsibleformyownmedicalinsurance.

IaminformedaboutandassumerisksassociatedwithVentureOutrelatedactivities.IunderstandthatIamresponsibleformyowndecisionsandsubsequentactionsandagree,asaparticipant,tothedutieslistedbelow:

DUTIES OF PARTICIPANTS

ParticipantshavethedutytoactinareasonableandprudentmannerwhenengaginginrecreationalactivitiesofferedbyVentureOut

ParticipantsmaynotparticipateinanyVentureOutadventurerelatedactivitywhileundertheinfluenceofalcoholicbeveragesand/orcontrolledsubstances

Participantsmaynotengageinharmfulconductorwillfullyand/ornegligentlyengageinanytypeofconductwhichcontributestoorcausesinjurytoanypersonorpersonalproperty

Participantsmaynotinterferewiththesaferunningandoperationoftheexpedition,includingfailuretousesafetyequipmentprovidedbyVentureOutorfailuretofollowthetripleader’sinstructionsinregardtosafetyorconduct

ParticipantsmustinformornotifythetripleaderofanyincidentoraccidentinvolvingpersonalinjuryorillnessexperiencedduringthecourseofaVentureOutrelatedactivity.Ifsuchinjuryorillnessoccurs,theparticipantshallleavepersonalidentification,includingnameandaddresswiththeVentureOutcenter.

ParticipantsmustadvisetripleaderorthetripguideofanyknownhealthproblemsormedicalconditionsalongwithanyprescriptionmedicationthatmaybeusedinthetreatmentofsuchhealthduringthecourseoftheVentureOutactivity

I,theparticipant,agreetoabidebyallVentureOut,Dept.ofRecreationalSports,andUniversitypolicies/procedures.IagreethatIwillsupportanalcohol/drugfreeenvironmentbynotconsumingalcoholordrugsduringthisevent.Ialsoagreetofollowtheinstructionandguidanceoftheuniversitysponsor.

Initial

 Virginia Tech does not discriminate against employees, students, or applicants on that basis or race, color, sex, sexual orientation, disability, age, veteran status, national origin, religion or political affiliation. Anyone having questions concerning discrimination should contact the Equal Opportunity and Affirmative Action Office. If you are a person with a disability and desire any assistance devices, services or other accommodations to participate in these activities, please contact David Goodman with Venture Out at 540‐‐‐231‐‐‐3750 during business hours of 10:00am‐‐‐ 

6:00pm, Monday‐‐‐Friday to discuss accommodations prior to the event.

PARTICIPANT INFORMATION 

I have read, understand and agree to the above listed terms, risks, and duties as outlined on the front side of this form. 

Participant’sSignature:

  Date:

 

ParentSignature(Ifunder18):

  Date:

 

 

ParticipantName:

StudentID#:

InsuranceCompany: Policy#:

Pleaselistanyphysicallimitationsand/ormedicalconditionsthatmayaffectyourparticipation:

Pleaselistanyprescriptionmedicationsthatyouarecurrentlytaking:

Pleaselistanyallergiestodrugs,chemicals,dusts,foods,animalsorpollens:

EmergencyContact:

Relation: Phone:

Address:

HaveyoueverbeenonaVentureOuttrip?

Howdidyouhearofus?

AUTHORIZATION TO USE PHOTOGRAPHS

By completion of this form, I irrevocably authorize Venture Out and the Dept. of Recreational Sports to copyright, use, and publish for any legal purpose, any and all photographs of me or the previously mentioned minor which may be taken during this expedition 

without further compensation to me. All photographs shall be solely the property of Venture Out.

 TripTitle: Date:

Name: Phone:

Address:

Email:

142McComasHall895WashingtonSt.SWBlacksburg,VA24061

540.231.4982ventureout@vt.edu