zs FullValueContract Co. Confidential Information PHYSICAUHEALTH INVENTORY FORM tn order for us to help you make good decisions about your parfiipafion in the Outoor Team Buating Workshop, please ‘complete this form thoroughly and thought. Witeanna oa Date of Bt. (msde) ‘Do you take any prescribed or over the counter medicaton reguiary? I so, what medicalion and for what condtion(s}? ‘Ace you allergic to anything? I so, what? ‘Please bring your personal medications) to the program. Do you use tobacco products? If so, how much? Do you use any orthopedic brave (ex. Kneo, back, et. ‘Have you been hospitalized within the last two years? Iso, for what reasons? Desarbe your curent exercise acti level Please note the Frequency, imaldistance and intonsily (leisurely, moderately or intensely) (Do you have any other medical condiions or physical lnitaions that we should be aware of” ‘The information provided here is complete and accurale statement ofthe physical factors which may affect my parcipation in (Outdoor Teambuaiding Workshop. This information wil be kept confidential, except in case of emergency. ‘FulVelueCortract Co. hes taken af reasonable precautions fo provide professional organization, supervision, instruction and ‘Safety equipment fr the program. | understand tht | may, in my sole iscrefon, refrain foe involvement in any acy, wich! ‘consider inappropriate for health or for any other reasons. ‘expressly agree, covenant end promise fo accept and assume all responsibilty and risk fr inh, ness, or ny damage to _mysel or my propery arising from my participation in his challenge course experience. | decide fo patcipate in these aches inspite ofthe risks. PRINT FULL NAME DATE: ‘SIGNED. EMAIL ADDRESS: ‘moments fo