Health Statement Clause Samples
A Health Statement clause requires a party, typically an individual, to declare their current health status as part of an agreement. This clause may involve disclosing any known medical conditions, recent illnesses, or confirming the absence of certain health risks, often in contexts such as insurance applications, employment, or participation in activities with health implications. Its core function is to provide transparency about health-related risks, enabling the other party to assess potential liabilities or make informed decisions based on accurate health information.
Health Statement. I acknowledge my Child is in excellent health and physical condition. I have disclosed any medical, physical, or mental health condition to Wanna Play Playcare in my Child’s Enrollment Form.
Health Statement. My child is in good health, with activity restrictions noted on the emergency card. Immunizations are up to date and on file with the school and/or appropriate waiver is on file with the school.
Health Statement. The proposed activity provided by the Angelina College Ropes Course, requires participation in physical exercises, which are, by their nature, physically demanding. Many of the activities will challenge you, and cause surges in blood pressure and pulse rates. It is imperative that you are free of any heart related or other diseases. Therefore, all participants must be free of medical or physical conditions, which might create undue risk to themselves or any others who depend on them. Good physical condition will increase your enjoyment of the outdoor activities. If there is any doubt about your ability to safely participate in the experience, you should have a physical examination. Participant Name: Male Female Age: Date of Birth: Street Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: Staff signature: Participant signature: In an EMERGENCY, please notify (provide name & relation): Where will this person be during the time you will be on the course? (if at work, please provide name of business) Home/Cell Phone: Work Phone: Have you had or do you currently have any heart problems (dates)? YES NO Do you frequently suffer from pains in your chest? YES NO Do you often feel faint or have spells of severe dizziness? YES NO Has a doctor ever told you that you have high blood pressure? YES NO Are you a smoker?Do you have arthritis, joint or back problems that might be aggravated by exercise? Have you had any operations or serious injuries (dates)? Do you have any disabilities or chronic recurring illnesses or communicable diseases? YES YES YES YES NO NO NO NO Are there any activities to be limited/discouraged by physician's advice? YES NO Do you have Epilepsy? YES NO Do you have Diabetes? YES NO Are you allergic to any medicines, insects or pollen? (Circle all that apply & identify where necessary) YES NO Do you have asthma? If so, how often do you use an inhaler? YES NO Are you currently pregnant? If so, how many months? YES NO Are you currently sick and/or using a medication that's not listed above? YES NO Do you carry family medical/hospital insurance? YES NO Carrier: Policy #: Suggestions or health related information for the Angelina College Ropes Course: General Health Statement (check one): Excellent Good Fair Poor This health history is correct so far as I know and I believe that my health is satisfactory to participate in ropes course activities.
Health Statement. Neither Camper nor anyone in ▇▇▇▇▇▇’s immediate family has suffered from or, to my knowledge, been exposed to COVID-19 within the past 45 days. Neither Camper nor anyone in ▇▇▇▇▇▇’s immediate family has experienced any of the following symptoms in the past seven days nor have they been on medication to alleviate any such symptoms in the past seven days: cough, sore throat, fever, shortness of breath, loss of smell and loss of taste. In the event Camper or anyone in ▇▇▇▇▇▇’s immediate family experiences any of the foregoing symptoms, I will notify the Club immediately and will not bring Camper back to the Club.
Health Statement. If my child needs the following, I authorize school personnel to administer (check all that apply) Acetaminophen (Tylenol) Ibuprofen (Advil/Motrin) Administration of “over the counter” medication will be at the discretion of the appointed personnel, consistent with the recommended does for age as defined on package guidelines. I agree to allow personel to administer over the counter medication as needed. Is the student diabetic? If Yes, is the student insulin-dependent? List all allergies (including food, medicines, vaccines, environmental, etc.) IF NO ALLERGIES, PLEASE STATE “NONE”: Special instructions if exposed to allergen: List any serious Illness, surgery, or injury of this past year: List any other medical problems (Include details on a separate sheet if necessary): Does the child currently wear: If you cannot be contacted in an emergency, please designate who to contact next: Emergency Contact Name Emergency Contact Phone # Cell Phone # Relationship
Health Statement a. I hereby certify that my child is in good health. If the child has any activity restrictions, please list
b. I hereby certify that my child’s immunizations are up-to-date.
c. I hereby certify that my child’s immunization record or appropriate waiver is on file with the child’s school.
Health Statement. The proposed activity provided by the Angelina College Ropes Course, requires participation in physical exercises, which are, by their nature, physically demanding. Many of the activities will challenge you, and cause surges in blood pressure and pulse rates. It is imperative that you are free of any heart related or other diseases. Therefore, all participants must be free of medical or physical conditions, which might create undue risk to themselves or any others who depend on them. Good physical condition will increase your enjoyment of the outdoor activities. If there is any doubt about your ability to safely participate in the experience, you should have a physical examination.
Health Statement. I understand that I am responsible for submitting a complete and accurate medical history on the forms provided by IPO or any follow-up forms required by IPO or my host institution, and I state that I have done so. I certify that I am free of medical conditions that would endanger my life, health, or well-being while traveling or living abroad, or that would impede my ability to fully participate in all aspects of the Program. I will follow my doctor’s advice on travel medicine, etc., and will follow the recommendations of the Centers for Disease Control (▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/travel/), provided that they do not conflict with my doctor’s advice, so that I will remain healthy on the program. I agree to take any medications, as prescribed, that are necessary to stay healthy, including medicines needed to manage mental illnesses or other chronic medical conditions. I also understand that if I do not make my medical or psychological needs known in a timely manner, IPO may delay my participation in the program until reasonable alternatives can be determined. I agree that if in the course of the program, the program director or the Director of Education Abroad determines in good faith judgment that the health, safety, welfare of myself or my fellow participants, or the integrity of the program experience, is jeopardized by my continued participation, I shall withdraw from the program and return to the United States, or be subject to expulsion. In such cases of medical withdrawal IPO will make every reasonable effort to ensure that I can receive partial credits or refund of program fees, where possible. I understand that I am responsible for requesting reasonable accommodations related to a disability in a reasonable time frame prior to departure. I understand that I must provide IPO and University of Massachusetts Disability Services with any documentation required in conjunction with my request for accommodations. I further understand that legal and cultural expectations are not the same overseas as they are in the United States, and that my requested accommodations may not always be available at all overseas sites or programs, but that IPO will make every effort to ensure such accommodations are available. I understand that for the duration of my program and specific to the official program dates, I will be covered by the UMass Out-of- Country Accident & Emergency Sickness Medical Coverage. I understand this coverage is only available outside the U.S. and does no...
Health Statement. Neither Participant nor anyone in Participant’s household has tested positive for Covid-19 in the previous 10 days. Neither Participant nor anyone in Participant’s household has had close contact in the previous 14 days with someone who, within 48 hours before or 10 days after such contact, tested positive for Covid-19, suspected they had Covid-19 or showed symptoms of Covid-19. Symptoms of Covid-19 may include fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea. Neither Participant nor anyone in Participant’s household has experienced any of the foregoing symptoms in the previous 10 days. In the event Participant or anyone in Participant’s household experiences any of the foregoing symptoms or is exposed to Covid-19, Participant will not return to the Club until cleared to do so by a healthcare provider.