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 Office of Student Life: ANNUAL EVENTS
Pre-Orientation: HEALTH FORM (Word Document)
This health statement is confidential.  It will be reviewed by the Instructor of the Outdoor Adventure Program.  It is designed to give the instructor a better picture of who you are so that we can better prepare for and serve your individual needs.  In the unlikely event of an injury this information will be shared with emergency medical personnel and could be the most important information we have about your medical history.  Please be as thorough as possible.  Thank you.

Office of Campus Recreation
Activity: Date:
Name:
Address:
City, State, Zip:
Phone: 		Stevens ID:
Height:
Weight:
DOB:

IN CASE OF EMERGENCY, CONTACT:
Name:
Address:
City, State, Zip:
Doctor's Name: 		Relationship:
Day Phone:
Evening Phone:
Doctor' Phone:

BACKGROUND:
First Aid Certification:
CPR Certification:
AED Certification:
Lifeguard Certification:
Swimming Ability:
Do you wear glasses?
Do you have Asthma?
Expiration Date:
Expiration Date:
Expiration Date:
Expiration Date:
Do you smoke?
Do you wear contacts?

HEALTH HISTORY:
Allergies Yes No Reaction
Penicillin
Erythromycin
Sulfa Products
Iodine
Food
  List:
Stings/Bites
  List:
Other
  List:

Please check any of the following conditions that could affect your performance during the activity:
Blackouts
Dizziness
Chest pain 
 Headaches
Stomach ailments
High blood pressure
 Menstrual cramps
Muscle cramps
Joint dislocations

When was your last tetanus shot? What is your blood type?
Please list any medications you are currently taking and for what condition:
Please describe conditions requiring ongoing medical attention or medication that could affect your performance during the activity (back injuries, dislocations, knee, etc.):
Do you have a history of heart problems?  Please describe:
Have you had any recent injuries or operations?  Please describe (what, when and current conditions):
Do you have any current illnesses? Please describe (cold, sore throat, etc.):
Do you have any fears or phobias?
What is your current level of fitness on a scale of 1-10?
How often do you exercise?
What type of exercise do you do?
Is there any other information that we should know about?

I hereby give authority to any hospital or doctor to render immediate aid as might be required at the time for my health and safety.  It is understood by me that all expenses of this service will be accepted by me.
Name of Participant:
Date:
Name of Parent if participant is under 18 years old:
 		Date:




EVENTS CALENDAR
PRE-ORIENTATION
Outdoor Adventure Participant Info Form
Health Form for Outdoor Adventure
Backpacking
Checklist
Canoeing Checklist
Mountain Biking/
Rock Climbing
Checklist
ORIENTATION
August 24, 2005
CONVOCATION
September 7, 2005
STUDENT
LEADER RETREAT
TBA
FRESHMEN
PARENTS' WEEKEND
September 23-25
STUDENT LEADER AWARDS DINNER
TBA
GRADUATION
May 25, 2006
EUROPEAN TRIP
 Intersession 2006
10th Floor Howe   Castle Point on Hudson   Hoboken, NJ 07030   T 201-216-5699   F 201-216-8946    

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