Outdoor Leadership Participant Medical Record

Personal Details

Avondale ID Number: *
Title: *
Full Name: *
Personal Email: *
Height (cms): *
Weight (kgs): *
General Practitioner Name: *
General Practitioner Phone: *
Medicare No: *
Date of last Tetanus vaccination: *
Do you have Private Health Insurance? *

Name of Private Health Insurance Provider: * Membership No.: *

Emergency Contact Details

Emergency Contact No. 1 Name: *
Emergency Contact No. 1 Phone: *
Emergency Contact No. 2 Name: *
Emergency Contact No. 2 Phone: *
Emergency Contact No. 3 Name:
Emergency Contact No. 3 Phone:

Medical Details

Do you have any of the following?
Check all that apply.

ADHDAspergersAutismBipolarDyslexiaDepression

Do you have any learning difficulties? *

Please provide details: *

Is your dental health up-to-date? *
Are you currently taking medication? *

Please provide details of the medication(s) and the dosage: *

Have you ever suffered from, or now suffer from, any of the following?
Check all that apply.

Abnormal shortness of breath
Anaphylaxis*
Anxiety attacks
Asthma
Bronchitis, pneumonia or pleurisy
Claustrophobia
Colour blindness
Concussion or head injury
Diabetes
Dizzy spells
Ear infections/operations/auditory problems/hearing aid
Ear, nose or throat problem
Epilepsy Grand Mal or Petit Mal*
Eye or visual problems/glasses/contact lenses
Fracture*
Hay fever
Heart disease
Hepatitis
Hernia or rupture
High blood pressure
Hypoglycaemia
Kidney or bladder disease
Known allergies*
Major joint or back injury*
Mental illness*
Motion sickness
Paralysis or muscular weakness
Prosthesis
Reactions to prescribed medicines*
Rheumatic Fever
Severe chest pains
Severe depression
Severe headaches or migraines
Severe period pain
Severe weight loss
Sinusitis
Skin disease*
Sleepwalking or frequent nightmares
Swollen or painful joints
Unconsciousness, fainting or blackouts
Unusual period bleeding
Vertigo - specify the height, speed and position

Please provide details: *

Have you had any operations? *

Please provide details: *

Have you had any other illness or injury already specified? *

Please provide details: *

Do you have nutritional issues (e.g. gluten or lactose intolerance etc.)? *

Please provide details: *

Swimming Ability: *

Non-swimmerBeginner-level swimmerConfident swimmerStrong swimmer

Acceptance of Risk

I have accurately and honestly completed this medical form.

I understand that outdoor leadership focuses on the development of my physical skills as well as the | theoretical understanding of the subject matter.

I understand the activities involved in this class, and I am confident that I will be able to participate in the physical activities.

I confirm that I have no previous injuries or illnesses that would limit my involvement.

I realise that engaging in these activities will place me at risk at times. I also understand that I can reduce the level of risk to myself by:

following the directions of my instructors
using my common sense
electing to apply the principle of challenge-by-choice (providing this does not endanger me or other participants or leaders).

I understand that outdoor settings could present a variety of dangers to me and that despite thorough planning and all possible care, accidents can occur. In the unlikely event that I suffer injury or illness, I agree that the organisers can arrange medical treatment and emergency evacuation services as they deem necessary for my safety or well-being.

I understand the activities associated with this class are potentially dangerous. I knowingly accept the risks to which I will be exposed and agree to release to the full extent of the law Avondale University Ltd, its employees and agents from responsibility for any injuries I may suffer due to my participation.

I acknowledge that my information to Avondale University on this form is complete and accurate, and I will inform the activity leader if there are any changes.

IMPORTANT: Upon submitting this form, you will receive a confirmation email. If you do not receive the email, contact Student Administration Services by emailing [email protected] or call +61 2 4980 2377.

We acknowledge the First Peoples of Awabakal and Guringai lands as traditional owners and custodians of the lands on which we study and work.
We pay our respects to Elders - past, present and emerging.