• 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. 

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  • 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.

  • Medical Insurance Information 

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  • Emergency Contact 

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  • Should be Empty: