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Awakening Fall 2019 Medical & Release Waiver
The Hartwick College Awakening Program involves a variety of activities in both indoor and outdoor settings.
Activities may include use of private and public transportation, warm-ups, games, group initiative problems, high and
low ropes course elements, hiking, canoeing, rock-climbing, and other rigorous physical adventure activities. These activities have deliberately and consciously been chosen to place program participants in challenging settings that elicit
some new insights and perspectives. The goal of Awakening, which is to raise participant awareness about themselves
and others through challenge, is thus supported by program activities. All activities are presented on a “Challenge by
Choice” basis. This means that the level of participation is up to the individual’s choice. Yet there is a risk, which must
be assumed by each participant, that due to the demands of certain activities he or she may incur injury. There are certain
risks inherent in outdoor adventure.

The information gathered on this medical form is intended to help inform Awakening staff of any pre-existing
medical conditions, and to help determine if consultation with your physician is recommended prior to your program. If
you have a pre-existing condition, participation in some of the more strenuous activities may not be recommended. This
information will be kept in strict confidence by Hartwick College and shared only with your permission.

More Program information can be found on the Awakening Program Information Document: https://docs.google.com/document/d/11sHF5hX_aRMgNivRGM--lH8cLSutJ954AdvbHS0tz3A

Email address *
Birth-date *
MM
/
DD
/
YYYY
First and Last name *
Your answer
Hartwick ID # (if unsure insert n/a) *
Your answer
Name of Health/Accident Insurance *
Your answer
Emergency Contact Name(s) and phone number(s) *
Your answer
Do you have any current certifications in (check all that apply) - *not required *
Required
What is your current level of fitness? *
Please rate your ability to swim
Please check the box(s) for any of the following conditions that apply to you: *
Required
For any conditions checked above, please describe: 1. Specific symptoms or conditions- what tends to cause the problems 2. how often they occur and how long they last 3. date of last occurrence 4. how you care for them, including any medications you carry for the above indicated conditions [write n/a if this does no apply to you] *
Your answer
Check any of the following box(s) that apply to you *
Required
Please explain any/all of the above checked box(s). [write n/a if this does not apply to you] *
Your answer
Please check any of the following box(s) that apply to you regarding allergies *
Required
For any of the above checked box(s) please explain 1. What happens during your allergic reaction 2. What medication or assistance is needed to control the allergy 3. Do you carry any medicine(s) to control this allergy - If so what are they? [write n/a if this does not apply to you] *
Your answer
RELEASE OF LIABILITY: I affirm that the confidential medical information that has been provided is accurate and complete. I understand that failure to disclose this information could affect my own safety and those around me, and I agree to hold Hartwick College harmless if full disclosure of a pre-existing medical condition has not been provided. In the event of illness or injury, consent is hereby given to provide emergency medical care, hospitalization or other treatment that may become necessary. I understand that parts of the Awakening Program may be physically or emotionally demanding. I hereby acknowledge that I am aware of these risks and I agree to follow all safety instructions and ask questions if I do not understand. I also acknowledge that, despite careful precautions, there are certain inherent risks of injury in this program, and I accept those risks.I understand that each participant must assume the risk of injury or disability that could result from any of the activities.I release, on behalf of my heirs and assigns, Hartwick College, its employees and successors, from and against any and all claims and causes of action arising out of my participation in this program, except insofar as such claim or cause of action arises from the actual negligence or intentional acts by Hartwick College, its officers, agents or employees. I have read, understand, and adhere to this statement. *
Required
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