Adventure Education Medical Questionnaire

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Responsibility and Preparedness 

Waiver & Release of Liability

Participants in the Adventure Education program may take part in activities including, but not limited to:

  • Hiking
  • Yoga
  • Rock climbing / Rock wall
  • Low ropes/high ropes
  • Backpacking
  • Glamping
  • Pre-orientation adventure day activities
  • Mountain & Urban biking
  • Ice skating
  • Ballroom dancing
  • Rafting & Kayaking
  • Skiing and Snowboarding

Participates should be aware that they may be exposed to dangers, risks, and/or hazards associated with participating which include the use of, act of, and/or exposure to, but not limited to the following:

  1. Unpredictable weather conditions including lightning, storms, wind, rain, snow, ice, cold, heat, weather  changes, and changes in water level, and potential problems associated with back country navigation;
  2. Travel in a vehicle driven by a person other than self;
  3. Use of specialized equipment and problems due to defects in manufacturer's products or arising from the improper use of products;
  4. Carrying/lifting over 50lbs;
  5. Physical exertion associated with the movements involved with outdoor adventure activities that can cause fatigue, soreness, sprains, abrasions, fractures, joint stiffness, and blisters;
  6. Wounds and injuries to skin, organs, muscles, joints, and bones;
  7. Uneven terrain, extreme temperatures or conditions;
  8. Contact with traffic, pedestrians, and/or other participants;
  9. Accidents, illness, or other problems in remote places without cell phones, other means of communication, or easy access to medical facilities;
  10. Injuries inflicted by animals, plants, UV rays, or other natural forces;
  11. Exposure to natural and man-made fire; and
  12. Hazards related to water including wading, swimming, or capsizing into water containing cold temperatures, rocks, trees, currents, rapids, re-circulating holes, waterfalls, man-made objects, or other obstacles in the water. This can result in hypothermia, injury, entrapment, or drowning.
Each Participant is responsible for determining if he or she is physically able to participate in the activities offered by the program. It is always advisable to consult a physician prior to participating in any Adventure Education activities.  I hereby acknowledge and understand that there are dangers and risks associated with the activities described above, which may not be fully explained to me.  I hereby agree to abide by all rules, instructions, policies and procedures imposed by Wilkes University relating to the use of the facilities, property and equipment.

Medical Questionnaire & Disclosure Agreement

This medical questionnaire provides us with information required for course management and emergency situations.  By requesting this medical history, we do not imply that we have the expertise to assess your physical condition, or your ability to participate safely in this program.   If you have any doubts about your ability to participate in this program, please consult with your physician.  Please complete fully so that instructors can adjust program activities as needed to meet your needs and manage your participation and the participation of others. This information is confidential and will be shared only as needed with trip leaders, instructors and medical care providers.

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