Ventura Wild Participant Personal & Medical Information
Print Participant's Full Name *
Your answer
Print Parent / Guardian Full Name *
Your answer
Program (s) *
Your answer
PLEASE Check APPROPRIATE RESPONSE: *
YES
NO
Any medical conditions which restrict participation in vigorous physical activity
Allergies to food, insects or plants of any kind
History of asthma
History of seizures
Does child carry an inhaler, epinephrine pen or other emergency medication
Regular medication being taken that we should know about
Recent surgery or other pertinent medical information
Any developmental or neurological differences that we should know about
Can your child swim *
**PLEASE PROVIDE DETAILS FOR “YES” RESPONSES ABOVE:
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**Please share with us any other physical or emotional ways your child might need extra support or awareness:
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Ventura Wild Medical Treatment Authorization ____________________________________________________I understand that I can lessen the inherent risks of outdoor activities at Ventura Wild by filling this form out in detail and carefully following the “To Bring” list. The above information is accurate and complete. I have read and understood the foregoing acknowledgement of risks, assumption of risks and responsibility, and medical authorizations. *
Required
In the event that this participant requires immediate medical attention, I hereby give my permission for a licensed physician or nurse to administer treatment as necessary. *
Required
Doctor's Name *
Your answer
Doctor's Phone Number *
Your answer
Medical Insurance Company *
Your answer
Policy Number *
Your answer
Group Number *
Your answer
Policy Holder Name *
Your answer
By checking here, I am effectively providing my signature, indicating that all the information on this form is true and accurate, to the best of my knowledge, and I agree to the terms and statements above. *
Required
Signature of Parent / Guardian *
Your answer
Date *
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YYYY
Thank You!
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