Emergency Medical and Health Statement

Student’s Name:        Date of birth:

Sex:  Male     Female       Religious Preference (if any):

Before a student’s application will be accepted, we must receive a current physician’s statement that the applicant has no known heart, lung, orthopedic, or blood-sugar imbalance problems that may be aggravated by mountaineering expeditions.

Check if any of the following conditions exists. Give details in the speace provided.

  Physical handicaps:

  Present medical treatments:

  Restrictions on physical activity:

  Restrictions on diet (food and drink):

  Allergies or reactions to medication:

  Problems with vision:

Check conditions that the student has had:   measles    mumps      chicken pox     appendicitis

Other serious accidents, illnesses, or surgeries:

Additional information regarding special medical needs and prescriptions:

Health/Dental Insurance information (name of company, policy holder, policy number, contact phone number and address, other details):

After filling out this page print it and return it with other forms.

Please attach a copy of vaccination records and copy of insurance cards (front and back). Please be sure that the tetanus booster is current.