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Medical Form

This document contains medical information for Imogen McCall who will participate in an outdoor experience at Belair National Park on May 8th for a course in human movement, exercise, and sport science. Imogen does not have any known allergies, medical conditions, or injuries. In the event of an emergency, her emergency contact is her mother Kylie Williams. Imogen acknowledges being informed of safety procedures and risks of the fieldwork activity and accepts responsibility for her own actions and decisions regarding participation.

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imogen
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19 views

Medical Form

This document contains medical information for Imogen McCall who will participate in an outdoor experience at Belair National Park on May 8th for a course in human movement, exercise, and sport science. Imogen does not have any known allergies, medical conditions, or injuries. In the event of an emergency, her emergency contact is her mother Kylie Williams. Imogen acknowledges being informed of safety procedures and risks of the fieldwork activity and accepts responsibility for her own actions and decisions regarding participation.

Uploaded by

imogen
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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WH

FIELDWORK SAFETY & MEDICAL ACKNOWLEDGEMENT S 73


This form may contain confidential medical information that maybe required in the event of
an emergency. This document is to be kept secure and must be destroyed on completion
of the activity.
Fieldwork activity OUTDOOR EXPERIENCE – BELAIR N.P. Dates 8Th May

Course HLTH 1039 FOUNDATIONS IN HUMAN MOVEMENT, EXERCISE & SPORT SCIENCE

Participant name Date of birth 14/09/2004


Imogen McCall
Phone no. Staff / Student no.
0434238660
Home address 96-98 Murray st Stockport

Emergency contact Kylie Williams


person
Relationship to you
Mother
Best phone no. Alternate phone
0415335531 no.
Alternate contact Scott mccall Phone no. 0424442581
person
Any known allergies no
(describe)
Allergy prevention No
strategies
Any symptoms of an no
onset
Treatment in event of no
occurrence
Any current no
medication

Any known medical


or physical no
conditions
Do you have No
asthma?
Asthma triggers and no
prevention
Asthma prevention no
strategies
Treatment in event of no
occurrence
Leg injuries in the no
last 12 months or of
note
Note any other
relevant medical
information
Acknowledgement of Information regarding this fieldwork activity:

x I have been provided with appropriate health and safety information for this fieldwork activity.
x I have been advised of foreseeable hazards associated with this activity.
x I will comply and co-operate with any reasonable instruction or university policy or procedure.
x I understand my behavior on this activity should not put the health and safety of myself or others at risk.
x I have sought counseling regarding any medical condition and the risks associated with this fieldwork.
x I have advised the Fieldwork Leader of appropriate medical advice that will assist in managing this condition.
x I understand that the activities involved have an element of risk to person and property, and although every effort is taken
to minimise this risk I accept that there is a possibility of harm occurring.
x I understand that although all possible care is taken, the University of South Australia cannot accept responsibility for
cancellations, loss or damage of equipment, or accidents that may occur as a result of the fieldwork activities.
x I accept responsibility for my own actions and decision to take part in this activity.
x I am aware of the Code of Conduct for Students, and acknowledge that if my actions are non-compliant I could be
removed from the activity at my own cost.

Staff / Student / Volunteer name: Imogen McCall Signed: Date:

If under 18 years: Parent / Guardian name: _____________________Signed: _________________________Date:_______

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