Austin Peay State University Participant Medical Information & Agreement

Medical Information & Agreement

Name- (First/Last)
Birth Date- (Month/Day/Year)
Emergency Contact- (Name/Relation)
Emergency Contact Number-
Please click all that occur or have occured in your life-
If yes was answered to any of the above items, please explain in the space provided- (If none, type N/A)
Mental Health-Please click all that occur or have occurred in your life-
If yes was answered to any of the above items, please explain in the space provided- (If none, type N/A)
Allergies? (including medicines, foods, bites/stings, etc.- when was your last allergic reaction and what happened?)
Medications? (List any and all medications you are currently using, including over the counter products.  Also identify name, dosage needed and how many times a day- only bring an amount adequate for the length of the trip in the original containers with dosages)
Hospitalizations? (list all visits within the last two years, and what you were treated for)
Do you have any dietary needs/preferences?
Can you swim?
Do you feel that you are physically and mentally capable of participating in Govs Outdoors trips?  
Required
Required
Required