Rebel Challenge Course Health History Form & Waiver
Please complete this form to provide pertinent health information for the participant. The challenge course staff will keep this information confidential, and information provided will assist staff in providing necessary accommodations, risk management protocols, and treatments to ensure that participants have a safe and fun experience at the course.
First Name
Your answer
Last Name *
Your answer
Group Name *
Your answer
Date of Session *
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DD
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YYYY
Date of Birth *
MM
/
DD
/
YYYY
I identify as: *
Height (feet' inches") *
Your answer
Weight (lbs) *
Participants must weigh at least 50 pounds to participate in high elements. Participants weighing more than 250 pounds may not be able to participate in all high activities for risk management purposes.
Your answer
Do you have any of the following allergies? (If none, check N/A) *
Required
Please elaborate on any allergies.
Your answer
Do you or have you experienced any of the following? (If none, check N/A) *
Required
Please elaborate on any medical experiences.
Your answer
Are you currently taking any of the following medications? (If none, check N/A) *
Required
Are you pregnant? *
Pregnant participants may not be able to participate in all activities for risk management purposes.
Do you have any additional history or special accommodations that we should be aware of? *
Your answer
Do you have any physical limitations that may affect you participation in physical activities? *
Your answer
Do you have adequate medical insurance?
Medical insurance is strongly encouraged to participate. Please review your personal insurance for adequate coverage. Some companies may specifically exclude high-risk activities, therefore, in case of injury all expenses will be borne by you.
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