Viterbo University - The University of Opportunity: Hope and Help

Medical Information for Off-campus Activities 

Students: The information provided on this form will be used if the student requires medical attention, the information on the form could be used by a health care provider. It is to be completed prior to off-campus trips and activities. Advisors: One copy of the completed form is to be kept with the faculty or staff advisor leading the trip. Another completed copy is to be left on campus with the administrative assistant in the Student Development Center.  

 

Name   Age   Organization

 

Any pre-existing injuries (ankles, knees, back) that may be aggravated by the activity?

If yes, please explain

 

 

Are you currently taking any prescription or non-prescription medication?

If yes, what are they and what are they for?

 

 

Do you have any heart conditions?

 

Do you have high blood pressure?

 

Do you have any allergies (food, bees, insects, or medicines)?

If yes, please explain

 

 

Do you have asthma?

 

Indicate any disabilities that might affect your ability to participate in this activity. 

 

 

In case of emergency, contact   Relationship   Phone  

Health insurance provider

Health insurance number(s)

 

 

 

Online signature

Signature of parent/legal guardian, if participant is under 18 years of age.