Professional Documents
Culture Documents
Health Consent Form
Health Consent Form
+($/7++,6725<$1'&216(17)250$'8/725&+,/'
.
<RXDUHDERXWWRWDNHSDUWLQDFKDOOHQJH³URSHV´FRXUVHH[SHULHQFHDQGRUFOLPELQJUDSSHOOLQJ³DFWLYLW\´RIIHUHGWKURXJKWKH%R\6FRXWV
RI$PHULFD/DXUHO+LJKODQGV&RXQFLORQ 08/18/2018 GDWH
:KLOHSDUWLFLSDWLQJLQWKHDFWLYLW\\RXZLOOXQGHUWDNHDZLGHYDULHW\RISK\VLFDODQGPHQWDOFKDOOHQJHVWKDWDUHFRPSDUDEOHWRDFWLYLWLHVZLWKZKLFK
\RXPD\EHPRUHIDPLOLDU0XFKRIWKHWLPH\RXZLOOEHHQJDJHGLQDFWLYLW\RI³PRGHUDWHH[HUWLRQ´ZKLFKLVFRPSDUDEOHWRQRUPDOZDONLQJ
JROILQJRQIRRWUDNLQJOHDYHVFDOLVWKHQLFVRUVORZGDQFLQJ)RUVKRUWSHULRGVRIWLPH\RXZLOOEHHQJDJHGLQDFWLYLW\RI³YLJRURXVH[HUWLRQ´
ZKLFKLVFRPSDUDEOHWRIDVWZDONLQJVORZMRJJLQJKHDY\JDUGHQLQJRUVKRYHOLQJVQRZ
,IDQ\RIWKHDERYHDFWLYLWLHVDUHGLIILFXOWIRU\RXGLVFXVV\RXUSDUWLFLSDWLRQLQWKHDFWLYLW\ZLWK\RXUSK\VLFLDQ,IWKHVHDUHDFWLYLWLHVLQZKLFK\RX
UHJXODUO\HQJDJHZLWKRXWGLIILFXOW\\RXVKRXOGEHILWIRUSDUWLFLSDWLRQLQWKHSURJUDP
)ROORZLQJDUHVSHFLILFPHGLFDOFRQGLWLRQVDERXWZKLFKSDUWLFLSDQWVVKRXOGDOZD\VVHHNWKHDGYLFHRIDSK\VLFLDQEHIRUHSDUWLFLSDWLQJLQWKH
DFWLYLW\
3UHJQDQF\FOLPELQJKDUQHVVFDQLQMXUHXWHUXV
.LGQH\RUOLYHUWUDQVSODQWFOLPELQJKDUQHVVFDQLQMXUHWUDQVSODQWHGRUJDQ
+HDOLQJIUDFWXUHRUMRLQWLQMXU\VKRXOGEHFOHDUHGE\WUHDWLQJSK\VLFLDQ
5HFHQWVXUJHU\VKRXOGEHFOHDUHGE\WUHDWLQJSK\VLFLDQ
'RZQV\QGURPHVKRXOGKDYH[UD\FKHFNIRUQHFNLQVWDELOLW\DVSHUUHFRPPHQGDWLRQRIWKH6SHFLDO2O\PSLFV
,I\RXRU\RXUSK\VLFLDQKDVDQ\TXHVWLRQVDERXWWKHSK\VLFDOUHTXLUHPHQWVRIWKHDFWLYLW\IHHOIUHHWRFRQWDFWWKHORFDOFRXQFLO
Health History
See reverse for Hold Harmless Agreement and Signature Line
Shubham Sanjeev Garg
3DUWLFLSDQW1DPH
)LUVW 0LGGOH /DVW
7HOHSKRQH
+RPH :RUN
3HUVRQDOSK\VLFLDQ
1DPH 7HOHSKRQH
,QFDVHRIHPHUJHQF\SOHDVHFRQWDFW
1DPH 7HOHSKRQH
6SHFLDOGLHWDU\FRQVLGHUDWLRQV
/LVWNQRZQDOOHUJLHV
/LVWUHTXLUHGPHGLFDWLRQV
,I\RXDUHDOOHUJLFWRLQVHFWVWLQJVGR\RXKDYHDQLQVHFWVWLQJNLWHJ(SL3HQ"<HV1R No
'R\RXZHDUFRQWDFWOHQVHV" <HV1R
No $UH\RXSUHJQDQW" <HV1R
No
+DYH\RXKDGRUGR\RXQRZKDYH+HDUWDWWDFN'LDEHWHV$VWKPD$QJLQD(SLOHSV\&KHVWSDLQV
'UXJ5HDFWLRQV+LJKEORRGSUHVVXUH+HDUWPXUPXU
,I\RXFKHFNHGDQ\RIWKHDERYHH[SODLQDQGLQFOXGHGDWH
'R\RXKDYHDQ\RWKHUPHGLFDOFRQGLWLRQVWKDWZHVKRXOGEHDZDUHRI"
+2/'+$50/(66$*5((0(17
,XQGHUVWDQGWKDWSDUWLFLSDWLRQLQWKHDFWLYLW\LQYROYHVDFHUWDLQGHJUHHRIULVNWKDWFRXOGUHVXOWLQLQMXU\RUGHDWK,QFRQVLGHUDWLRQRI
WKHEHQHILWVWREHGHULYHGDIWHUFDUHIXOO\FRQVLGHULQJWKHULVNLQYROYHGDQGLQYLHZRIWKHIDFWWKDWWKH%R\6FRXWVRI$PHULFDLVDQ
RUJDQL]DWLRQLQZKLFKPHPEHUVKLSLVYROXQWDU\,KDYHFDUHIXOO\FRQVLGHUHGWKHULVNLQYROYHGDQGKDYHJLYHQFRQVHQWIRUP\VHOIRU
P\VRQRUGDXJKWHUWRSDUWLFLSDWHLQWKHDFWLYLW\DQGZDLYHDOOFODLPV,RUZHPD\KDYHDJDLQVWWKH%R\6FRXWVRI$PHULFDWKHORFDO
FRXQFLOWKHDFWLYLW\FRRUGLQDWRUVDQGDOOHPSOR\HHVYROXQWHHUVUHODWHGSDUWLHVRURWKHURUJDQL]DWLRQVDVVRFLDWHGZLWKWKHDFWLYLW\
,DPQRWXQGHUWKHLQIOXHQFHRIDQ\FKHPLFDOVXEVWDQFHLQFOXGLQJDOFRKRO8QGHUVWDQGLQJWKDWDQ\SK\VLFDODFWLYLW\LQYROYHVDULVNRI
LQMXU\,XQGHUVWDQGWKDWP\SDUWLFLSDWLRQLQWKHDFWLYLW\LVHQWLUHO\YROXQWDU\,UHOHDVHWKH%R\6FRXWVRI$PHULFDWKHORFDOFRXQFLO
WKHDFWLYLW\FRRUGLQDWRUVDQGDOOHPSOR\HHVYROXQWHHUVUHODWHGSDUWLHVRURWKHURUJDQL]DWLRQVDVVRFLDWHGZLWKWKHDFWLYLW\IURPDQ\
DQGDOOFODLPVRUOLDELOLW\DULVLQJRXWRIWKLVSDUWLFLSDWLRQ7KLVUHOHDVHGRHVQRWKRZHYHUDSSO\WRDQ\KDUPFDXVHGE\QHJOLJHQFHRU
ZLOOIXOPLVFRQGXFWRIWKHORFDOFRXQFLORULWVHPSOR\HHV
,QFDVHRIHPHUJHQF\LQYROYLQJP\FKLOG,XQGHUVWDQGHYHU\HIIRUWZLOOEHPDGHWRFRQWDFWPH,QWKHHYHQW,FDQQRWEHUHDFKHG,
KHUHE\JLYHP\SHUPLVVLRQWRWKHSK\VLFLDQVHOHFWHGE\WKHDGXOWOHDGHULQFKDUJHWRVHFXUHSURSHUWUHDWPHQWLQFOXGLQJ
KRVSLWDOL]DWLRQDQHVWKHVLDVXUJHU\RULQMHFWLRQVRIPHGLFDWLRQIRUP\FKLOG
,KHUHE\DVVLJQDQGJUDQWWRWKH%R\6FRXWVRI$PHULFDWKHULJKWDQGSHUPLVVLRQWRXVHDQGSXEOLVKWKHQDPH
SKRWRJUDSKVILOPYLGHRWDSHVHOHFWURQLFUHSUHVHQWDWLRQVDQGRUVRXQGUHFRUGLQJVPDGHRIP\FKLOGE\WKH%R\6FRXWVRI
$PHULFDDQG,KHUHE\UHOHDVHWKH%R\6FRXWVRI$PHULFDIURPDQ\DQGDOOOLDELOLW\IURPVXFKXVHDQGSXEOLFDWLRQ
,KHUHE\DXWKRUL]HWKHUHSURGXFWLRQVDOHFRS\ULJKWH[KLELWEURDGFDVWHOHFWURQLFVWRUDJHDQGRUGLVWULEXWLRQRIVDLGSKRWRJUDSKV
ILOPYLGHRWDSHVHOHFWURQLFUHSUHVHQWDWLRQVDQGRUVRXQGUHFRUGLQJVZLWKRXWOLPLWDWLRQDWWKHGLVFUHWLRQRIWKH%R\6FRXWVRI
$PHULFDDQG,VSHFLILFDOO\ZDLYHDQ\ULJKWWRDQ\FRPSHQVDWLRQ,PD\KDYHIRUDQ\RIWKHIRUHJRLQJ