All participants must complete this form.

Date of Trip __/__/__

Name _____________,____________________ Phone (__)____________

Last First Middle

Age ____ Gender - F / M

Parent(s) or Guardian (for student participants only) __________________________

Work Phone (__)____________ Home Phone (__)____________

Home Address ________________________________________________

City _____________________ State __ Zip Code _______

In an emergency, please notify:

o Check here if same as above.

Name _______________________________ Relationship _________________

Work Phone (__)____________ Home Phone (__)____________

Home Address ________________________________________________

City _____________________ State __ Zip Code _______

Family physician: _______________________ Phone (__)____________

Name of Insurance Company _________________________________________

Policy and/or ID Number ___________________________________________

Participant's Health History

All participants must complete this form.

Please check any allergies participant may have:

Allergies: Type of Reaction:

o Insect Stings _________________________

o Hay Fever _________________________

o Asthma (allergy induced) _________________________

o Seafood _________________________

o Penicillin _________________________

Other: _____________ _________________________

_____________ _________________________

-over-

Please check any of the following diseases participant has had or has now:

Please answer the following questions:

Any specific activities to be encouraged, limited or avoided? ________________________

_______________________________________________________________________

Is participant able to swim? o yes o no Please comment on level of ability: _______________________

Does participant have a current tetanus shot? o yes o no Date of shot: __/__/__

Current medications (please send with directions if to be administered during trip): _______ ________________________________________________________________________

I give permission for my child to be administered: (Please check all that apply.)

o Tylenol o Cough drops o Antacids

as needed for minor discomfort while on a CRS educational field trip.

Special dietary considerations: _______________________________________________

Other health related information for field trip staff: ______________________________

_______________________________________________________________________

ALL CLEAN FIELD TRIP PARTICIPANTS PLEASE READ AND SIGN THE FOLLOWING:

This health history is correct so far as I know. I understand that participation in Cahaba River Society (CRS) CLEAN activities is entirely voluntary. I understand that the CRS field trip may involve: swimming, canoeing, hiking, camping, fishing and other outdoor activities and sports. I know and understand the risks and dangers involved in the above-named activities and I know and understand that unanticipated dangers might arise. I hereby release CRS from any responsibility for injury which might occur as a result of participation in CRS activities. I give permission for ______________________ to participate in all field trip activities, except as noted. I also give permission to authorize personnel to carry out such emergency diagnostic and therapeutic procedures as may be necessary for me or my child, and also permit such treatment procedures to be carried out at and by the local hospital(s) for me or my child in the event of an emergency. I understand that any medical expenses will be billed directly to me or my insurance company.

______________________________ ____________________

Signature of parent/guardian or adult participant Date