Electronic Medical Forms and Waivers

Medical Form

UNCG collects this medical information to be aware of any potential medical conditions that may arise during your participation in Team QUEST and to facilitate efficient medical attention, as necessary. The information on this form is strictly confidential and may be protected by The Federal Educational Rights and Privacy Act if participant is an enrolled UNCG student. This information will be shared only in the event of a medical emergency.

Name of Group: * Please enter your name.

Name: * Please enter your name.

Date: *

Please enter valid date.

Address: *

Please enter address.

UNCG (9 digit) Number * Please enter your answer here.

Phone: * Please enter your phone number.

Email Address: * Please enter your email.

Gender: * Please select one here.

Age: * Please enter your answer here.

Height: * Please enter your answer here.

Weight: * Please enter your answer here.

Do you have health insurance? *

Yes

Please select at least one choice above.

Contact in case of an emergency: * Please enter your name.

Relationship: * Please enter your answer here.

Emergency Contact’s Phone #: * Please enter your phone number.

If you have a disability, you may self-report to the Director of Team QUEST at (334-4968) and request a reasonable accommodation to participate. Please make a request at least two (2) weeks before the program.

Please bring all medications with you in case you need them.

1. Medical History: Do you have, or have you had any of the following conditions: Please provide any information that may be helpful to EMT if condition(s) present during a Team QUEST program.

a. Chest pains or heart concerns. Yes or No. If yes, please describe * Please enter your answer here.

b. Dizziness or fainting Yes or No. If yes, please describe * Please enter your answer here.

c. Fracture or dislocation Yes or No. If yes, please describe * Please enter your answer here.

d. Are your currently pregnant Yes or No. If yes, please describe * Please enter your answer here.

e. Asthma Yes or No. If yes, please describe * Please enter your answer here.

f. Seizures Yes or No. If yes, please describe * Please enter your answer here.

g. Diabetes or elevated blood sugar Yes or No. If yes, please describe * Please enter your answer here.

Please indicate if you are allergic to any of the following:

e. Bee Sting Yes or No, If yes, how do you react? * Please enter your answer here.

f. Food Yes or No, Please list foods: * Please enter your answer here.

g. Poison Ivy Yes or No, If yes, how do you react? * Please enter your answer here.

h. Medications Yes or No. If yes, Please list medications: * Please enter your answer here.

i. Other and How do you react? * Please enter your answer here.

j. What medication do you carry for allergic reactions? * Please enter your answer here.

k. Will these or any other physical, mental, or emotional problems and/or concerns, temporary or permanent, diagnosed or not, affect your participation? Yes or no, If yes, please identify and explain: * Please enter your answer here.

Initial Here

I am aware there is a 250-pound weight limit on certain challenge course elements that could prevent me from climbing if I exceed this weight limit. * Please click the yellow area and provide your initials here.

Please list any food restrictions including allergies if lunch is provided: * Please enter your answer here.

Initial Here

. Any information listed above will not pose any barrier to my participation in the program * Please click the yellow area and provide your initials here.

I certify that the information on this form is complete and accurate. I authorize The University of North Carolina at Greensboro (UNCG) to obtain or provide emergency medical care. I understand that I am solely responsible for providing my own health insurance and for all medical expenses related to my participation in Team QUEST programs. *If participant is less than 18 years old, the undersigned parent or legal guardian authorizes participation by minor and acknowledges acceptance of all terms of this agreement.

Signature of Participant *

Click to sign

Please sign here.

Signature of Parent/Legal Guardian (if under 18)

Click to sign

Please sign here.

Print Participant Name * Please enter your name.

Print Parent/Legal Guardian Name Please enter your name.

Say goodbye to paper waivers with electronic medical waivers.

Medical Form