Participant Medical/Health Information

  • Participant Information

    • Date Format: MM slash DD slash YYYY
  • The information recorded on this form is intended for use by the program’s leader or emergency medical personnel

  • Parent/Guardian Information

  • Emergency Contact Information

  • Please provide contact information for other people who know your child and with whom we can consult if we cannot reach you. We assume you have spoken with these individuals and they are willing to assist should the need arise.

  • Insurance Policy Information

  • I understand that Iowa State University does not carry health or accident/medical insurance for participants in the Swim & Gym Program.

  • Medical/Health Information

  • Health Condition of the Participant

  • Participants must be healthy and reasonably fit to safely participate in recreation activities. By signing this Parental Permission Agreement, you agree:

    • That your child has the physical fitness, ability and skill level to participate safely in the specified physical fitness activities included in this Program.
    • To inform the Program Director of any medication, ailment, condition, or injury that may affect your child’s performance in Program activities.
    • That you will bear all financial responsibility for any medical treatment arising from your child’s participation in the Swim & Gym Program.
  • Parent/Guardian Authorization for First Aid and Health Care

  • This Medical/Health Information form is correct and complete to my knowledge. My child (Participant) has permission to participate in all Swim & Gym Program activities except as explained in writing to the Program Director. I hereby give permission to the Swim & Gym Program staff to provide routine first aid if needed. If I cannot be reached in an emergency, I give permission to Program staff to seek emergency treatment including x-rays, routine tests, and treatment for the health of my child.

    • Date Format: MM slash DD slash YYYY
  • Press "Submit" to continue to the program departure release form.