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Lyon Education Adventure Program Medical Form

Personal and Group Responsibility:

Participation in all activities through Lyon College, regardless of location, is voluntary on behalf of all participants. All participants agree to cover the full cost of any possible physical harm or injury to themselves or others, and damage or loss of personal items (including personal vehicles) through insurance or personal resources.

I realize that I represent Lyon College and myself. I am fully aware that the off campus trip policy is enforced for the program in which I have enrolled. I acknowledge and understand that failure to truthfully and accurately disclose the required information in this form could result in serious harm to my fellow participants and myself. I give Lyon College staff, trip leaders, and emergency personnel consent and permission to provide first aid and emergency medical treatment in the event I am injured. I understand the safety and welfare of the group take precedence over any individuals concerns. Conduct that may jeopardize or endanger the trip participants or trip leaders will not be tolerated and may result in expulsion from the program at my own expense. I understand that after registration, there is no refund unless the LEAP cancels the program. I understand that if I am at all uncertain about my ability to participate in this program, it is my obligation to consult my personal physician.

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Click to customize section title

Student ID#:
Affiliation*
Student
Faculty
Staff
Non-College

Height *

Weight (lbs) *
Shoe Size*
Do you wear eye glasses/contacts*
No
Yes
Can you swim?*
No
Yes
Are you currently certified in (check all that apply):
First-Aid
First Responder
EMT
CPR
Medical Information

List any allergies you may have. Include medicines, foods, bites, stings, etc. Include reaction and medications needed.

Medications: List any medications you are currently taking. Include conditions, dosage, frequency, and side effects (if any).
Health Profile. Check all that apply: *
Pregnant
Require medical equipment
Seizure within past year
Hospitalization/emergency room visit within past year
Surgeries within past year
Neck/back/shoulder/knee/ankle problems
History of heart attack or other heart problems
Other medical issues illness/symptoms needs
Do you have diabetes, NIDDM or IDDM?
Do you have elevated blood cholesterol or triglycerides
Do you smoke?
Do you consume more than one alcoholic beverage per day?
NONE OF THE ABOVE

If you checked any boxes in the Health Profile section, please provide a detailed description including symptoms and restrictions.

Fitness Profile: Current Exercise Activity: Include activity, frequency, and intensity. IF NONE, TYPE "NONE" *
Dietary Restrictions/Food Preferences

Please list any dietary or food preference that you may have:
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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