Program FormsIf you need assistance or have any questions, please contact Claire at programs@summitlead.org or (512) 677-5117 Participant Waiver FormInstructions: Download, print, sign, & bring to check-in(or email at least 24 hours in advance of program start to programs@summitlead.org Download Waiver Participant Info & Medical History FormTo register more than 1 participant, return to this form after submitting. Open Form Participant Info & Medical History PARTICIPANT INFORMATION Participant Name * First Name Last Name Contact Email * Contact Phone * (###) ### #### Mailing Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Gender * Male Female Prefer not to answer Date of Birth * MM DD YYYY LEADERSHIP & FAITH Leadership Role(s) Are you currently serving in any leadership roles (professional or volunteer)? Faith Are you actively practicing any faith / religion? Church Are you actively involved in a local church? If so, where? MEDICAL INFORMATION Physical Accommodations Please describe any physical limitations that change how you participate in physical exercise and/or outdoor activities: Dietary Restrictions Please describe, so we can do our best to accommodate your dietary needs. Also advise if you will bring any substitute food to the event. Allergies Please describe any environmental, food, drug, or other allergies. (1) What you react to, (2) Your typical reaction, (3) Recommended treatment. Medication & Drugs Please describe any medications and/or drugs you regularly take (prescription, over-the-counter, or recreational). Please advise if you will be bringing these items with you. (Note: A wilderness trip is not a good time to detox or stop a doctor-prescribed regimen.) Medical History COVID-19 or other infectious disease within the last 9 months Asthma, wheezing, or shortness of breath Heart conditions Diabetes Seizures Pregnancy (current or within the last 12 months) Problems with menstruation/periods Recent sports injury or other muscular/skeletal Recent hospitalization or surgery Recent international travel Treatment for emotional or behavior difficulties Treatment for eating disorder Recent significant life event that continues to impact life More info If you checked any of the above, please elaborate: EMERGENCY INFORMATION Emergency Contact * First Name Last Name Emergency Contact Phone * (###) ### #### Primary Doctor (or other preferred health-care provider) Healthcare Contact Phone (###) ### #### Healthcare Insurance Company Insurance Policy Number (or subscriber information) Insurance Contact Phone (###) ### #### AUTHORIZATION Authorization for Health Care * This health history is correct and accurately reflects the health status of the participant to whom it pertains. The person described has permission to participant in all program activities except as noted by me and/or an examining physician. I give permission of the physicians selected by the organization to order x-rays, routine tests, and treatment related to the health of person described for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this person. I understand the information on this form will be shared on a "need to know' basis with program staff. I give permission to photocopy this form. In addition, the organization has permission to obtain a copy of the described person's health record from providers who treat them and these providers may talk with the program staff about their health status. Yes, I agree and give consent. No, please contact me. I am completing this form * for myself. on behalf of a minor for whom I am legally responsible. Name of person completing Health Profile * By typing my name, I submit the information as a legal signature, signed at the date and date indicated by the form submission data. First Name Last Name Thank you!
