Medical History Form
The information provided on this form is being collected to assist in the event of an emergency situation. It is recommended that your emergency contact(s) have knowledge of any medical condition(s) you may have. The original of this form will be kept in a secure file in the WRS main office and a copy will be kept in a sealed envelope with the Primary Person in Charge in the field. The sealed field envelope will be shredded upon completion of the project/course. The other copy will be kept secure for five years and then shredded.

All individuals participating in a field activity should be reasonably fit and have no medical conditions which could potentially be expected to result in a life-threatening situation. If you have a serious medical condition or a condition that could be exacerbated during this time it is your responsibility to provide information on those conditions to assist with ensuring your health and well-being during the field activities (e.g. severe allergies, asthma, bleeding disorder, diabetes, epilepsy, heart condition, pregnancy). If you are taking medication, you should take an adequate supply for the length of the field activity. Any prescription medication that could affect your ability to perform the tasks required; or reduce your level of concentration or ability to respond should be disclosed.

It is recommended that all individuals participating in a field activity should have a current tetanus booster.
Freedom of Information and Protection Act: The personal information collected on this form is collected under the authority of the FOIPP Act to assist in the provision of care in emergency situations. The information provided will be reviewed by Wilderness Rescue Solutions Administration Staff and the Head Instructor of your field experience. Personal information is protected under the FOIPP Act.

For further information, contact the Operations Manager at 705-741-2248 or wildernessrescuesolutions@gmail.com
Email address *
Participants Full Name *
Your answer
Date *
MM
/
DD
/
YYYY
Name Of The Course You Are Taking *
Your answer
Phone Number *
Your answer
Age
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
Relationship To Emergency Contact *
Your answer
Please Choose All Conditions You Have Been Diagnosed With Past Or Present *
Required
If You Checked Yes For Asthma Do You Carry A Puffer
If You Checked Yes For Asthma When Was Your Last Asthma Attack
Your answer
If You Checked Yes For Asthma Is Your Asthma Sports Induced or Environmental
Your answer
Do You Have Allergies To Any Of The Following *
Required
If You Checked Yes To An Allergy Please List What You Are Allergic To
Your answer
If You Checked Yes To Allergies What Happens When You Are Exposed To Your Allergen
Your answer
If You Checked Yes To Allergies Do You Carry An EPI-PEN
Are You Currently Taking Any Medications - Prescription, Over The Counter, Herbal or Recreational? If Yes Please List Medications
Your answer
List Any Surgeries You Have Had
Your answer
Do You Have Any Previous Injuries To Any Of The Following *
Required
If You Checked Yes To A Past Injury Please Give Us Some Details About The Injury
Your answer
Do To The Intensity Of Our Training & The Use Of Realistic Scenarios & Make-UP We Like To Make The Instructor Aware If You Have A History Of Any Of The Following So The Instructor Can Adjust Accordingly *
Do You Have Any Other Medical Conditions Or Histories That Could Affect Your Safety Or Comfort Or The Safety Or Medical Wellbeing Of Other Course Participants Or Course Staff, During The Course That Your Instructor Should Be Aware Of
Your answer
Affidavit
I hereby state that I have included all information to the best of my knowledge and truthfully relating to my physical condition prior to conducting this course. I have made the course instructor aware of any medical conditions I may have. I realize that admission of a medical history is not grounds for dismissal from the course however I assume all risk and release Wilderness Rescue Solutions from any liability should my condition be adversely effected by the course content or its nature.

By Checking The Yes I Sign below Box & Typing Your Name which shall serves as an electronic signature:

1. I acknowledge that I have informed my Emergency Contact(s) of this designation and all aspects of the
field activity including the nature of any potential hazards.

2. I consent to the disclosure of the information in this document as necessary in the event of an emergency.

3. I acknowledge that it is my responsibility to disclose any medical, or other, condition that could endanger
my health and safety and that of my fellow participants.

4. I ACKNOWLEDGE THAT NO SPECIAL RELATIONSHIP IS CREATED BETWEEN WILDERNESS RESCUE SOLUTIONS AND MYSELF DUE TO ANY MEDICAL DISCLOSURE OR EMERGENCY CONTACT APPOINTMENT MADE HEREIN. DISCLOSURE OF THE INFORMATION HEREIN SHALL NOT CREATE A DUTY OF CARE BETWEEN WILDERNESS RESCUE SOLUTIONS AND MYSELF.
I Hereby Sign This Electronic Document *
Required
Your Typing Your Name Below Shall Serve As An Electronic Signature On Your Behalf *
Your answer
I Am A Legal Guardian For A Minor Who Is Under The Age Of 18 & I Am Legally Signing On Their Behalf & I Have The Authority To Do So
Your answer
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