Medical Information Form - 2020 Winter Mountaineering School Programs
ADK Mountain Club, Inc.
PO Box 867, Lake Placid, NY 12946
(518) 523-3441


Please provide complete answers to all questions:
Email address *
GENERAL INFORMATION:
Name: *
Your answer
Gender: *
Phone #: (Day) *
Your answer
Phone #: (Evening) *
Your answer
Address: (Street/PO Box, City, State, ZIP) *
Your answer
Program: *
EMERGENCY CONTACT:
(Parent or guardian information if participant is under 18 years old)
EMERGENCY Contact Name: *
Your answer
Emergency Contact Relationship: *
Your answer
Emergency Contact e-mail: *
Your answer
Emergency Contact Phone #: (Day) *
Your answer
Emergency Contact Phone #: (Evening) *
Your answer
Emergency Contact Phone #: (cell) *
Your answer
Emergency Contact Address: (Street/PO Box, City, State, ZIP) *
Your answer
INSURANCE COVERAGE:
Participant is responsible for his/her own medical expenses. ADK requires that anyone participating in a program have their own medical coverage in the event that an injury occurs to the participant either before or after the program begins. The information requested below is for the primary family policy holder.
Insurance Company Name: *
Your answer
Insurance Company Phone #: *
Your answer
Insurance Certificate/Policy ID#: *
Your answer
Insurance Group # (if applicable):
Your answer
Insurance Company Address:(Street/PO Box, City, State, ZIP) *
Your answer
Name of Insurance Policy Holder: *
Your answer
Policy Holder Phone #: *
Your answer
Policy Holder Address: (Street/PO Box, City, State, ZIP) *
Your answer
Policy Holder Place of Employment: *
Your answer
Physician/Primary Care Provider Name: *
Your answer
Physician/Primary Care Provider Phone #: *
Your answer
MEDICAL AND PHYSICAL INFORMATION:
Date of Birth: *
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Age (years): *
Your answer
Height: *
Your answer
Weight (lbs): *
Your answer
Date of Last Tetanus Booster: (ADK recommends within 10 years) *
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Please detail your current physical activity below including: activity type, frequency per week, approximate time/distance, and intensity level. *
Your answer
Swimming Ability: (we never plan on swimming in winter!) *
Do you have any allergies? *
If you have allergies, please list each allergy (including medicines, food, bites, stings, shellfish, iodine, plants, and animals), the type of reaction, and any medication required.
Your answer
Are you taking any prescription or non-prescription medication? *
If you are taking any prescription or non-prescription medication, please list each medication, the condition for which you are taking it for, the month/year initiated and any side effects.
Your answer
Please list all dietary restrictions: (Be Specific: vegetarian, no red meat, lactose intolerant, food allergies, strong food dislikes etc.)
Your answer
Have you had any operations or serious injuries in the past five years? (yes or no) If yes, please explain. *
Your answer
Have you been hospitalized or had any emergency room visits in the past year? If yes, please explain. *
Your answer
Do you have diabetes? If yes, are you insulin dependent? *
Your answer
Do you have epilepsy or a seizure disorder? If yes, please indicate the date of your last seizure. *
Your answer
Are there any other past or current medical issues/illnesses/requirements? If yes, please explain. *
Your answer
Have you had any of the following: heart attack, by-pass surgery, angioplasty, angina, or unexplained fainting? If yes, please explain. *
Your answer
Do you have any other cardiac conditions, including a heart murmur or irregular heartbeat? If yes, please explain. *
Your answer
Do you have high blood pressure, even if being treated with medication? If yes, list BP with date from last doctor's visit. *
Your answer
Do you have any muscle, bone or joint injury? If yes, please explain. *
Your answer
Do you have any neck, back, knee, shoulder, or ankle problems? If yes, please explain. *
Your answer
Have you ever had frostbite, circulatory problems or heat stroke? If yes, please explain. *
Your answer
Do you have any bleeding disorders, anemia? If yes, please explain. *
Your answer
Are you pregnant? If yes, what trimester?
Your answer
Do you smoke? *
Do you have asthma or other respiratory problems? If yes, please explain. *
Your answer
Are there any other medical conditions not covered earlier in this form which may affect or limit participation? If yes, please explain. *
Your answer
IF PARTICIPANT IS UNDER 18 YEARS OLD, PLEASE COMPLETE THE FOLLOWING THREE QUESTIONS:
Has the participant had counseling with a psychiatrist/psychologist/counselor within the past two years?
If the participant has had counseling with a psychiatrist/psychologist/counselor within the past two years, is it currently ongoing?
Additional Emergency Contact (other than parent or guardian listed earlier) Name, Relationship, e-mail, phone# day, phone# evening, cell #.
Your answer
Please review this form to be certain you have completed every question. This complete medical form is required for participation in this ADK program. All information on this form is confidential. It is possible to complete many ADK programs with a variety of medical/psychological difficulties, but ADK must be aware of these conditions. Failure to disclose medical and health history information as requested could result in serious harm to you and participants in your program.The status of your participation will be determined after review of this form. In some cases further evaluation, possibly including consultation with your health care provider, may be necessary. ELECTRONIC SIGNATURE REQUIRED. By Clicking YES and entering your name below, consent is hereby given for the applicant to attend an Adirondack Mountain Club program. Permission is given for ADK staff, volunteers, representatives or contractors to obtain or provide medical care for me/my child, or to transport me/my child to a medical facility. I further authorize ADK staff, volunteers, or other medical personnel to render such treatment they consider necessary for my/my child’s health and I agree to pay all costs associated with that care and transportation. I have read and understand both sides of this medical form and the information I have provided is, to the best of my knowledge, correct and complete. *
Name: (First & Last) *
Your answer
Todays Date: *
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A copy of your responses will be emailed to the address you provided.
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