Northern Illinois University

Required General Medical and Health Information

Campus Recreation – Outdoor Adventures

The following medical and health information will help in the unlikely event of an accident or illness. Please complete this form accurately and truthfully. The facts that you disclose will be confidential and will only be accessed to help the staff respond to your needs.

Full Name:*

First NameLast Name

Current Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number:*

Area CodePhone Number

Name of your personal physician:*

Phone number of personal physican:*

Do you have any physical or psychological limitations that might affect your ability to participate in the trip for which you have registered? If yes, please explain.*

Have you had or been exposed to any contagious disease or illness in the past 6 months? If yes, please explain.*

Do you have any allergies? If yes, please explain (including medications and environmental factors)*

Have you had a tetanus shot in the last 10 years?*

Has your appendix been removed? If so, when? *

Do you have a history of any medical conditions? (spinal problem, asthma, etc.?) If so, please explain.*

Are you currently taking any medications? If yes, please list each.*

Is there other important information pertaining to your health that might affect your participation in this activity? *

Medical Services Authorization and
Fitness for Participation Disclosure

Should I or my son/daughter/individual(s) for whom I have guardianship (as applicable) become ill or injured, I give permission for the Campus Recreation’ employees to render first aid and to seek emergency medical or rescue services, as they see fit, at my cost. I also hereby give my permission for myself/son/daughter or individual(s) for whom I have guardianship (as applicable) to receive emergency medical attention from a physician or other emergency medical responder in the event of illness or injury. To the best of my knowledge and belief, I/my child/individual(s) for whom I have guardianship are physically, emotionally, and mentally fit and to participate in this Campus Recreation program. I have completed this form with health disclosure information that is accurate, complete, and true to the best of my knowledge. I promise to have personal medical insurance in effect during the time of the activity. If the information provided is inaccurate or incomplete on this form or if I do not have medical insurance in effect, I understand that I will not be allowed to participate in this activity. I agree to notify Campus Recreation’ employees of any changes to my health, fitness or medical insurance status that may occur before or during the program.

Today's Date:*

Electronic Signature:*

If participant is under 18 Today's Date:

Signature of parent/guardian:

Medical Insurance Information

Issued in the name of:*

Address of insured:*

Relationship to name insured:

Name of insurance company:*

Insurance Company Phone Number:*

Area CodePhone Number

Address of Insurance Company:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Policy number:*

Emergency Contact

Emergency Contact Name:*

First NameLast Name

Emergency Contact Phone Number:*

Area CodePhone Number

Relationship of Emergency Contact:*

Medical Services Authorization and Fitness for Participation Disclosure

Medical Services Authorization and
Fitness for Participation Disclosure