SayPro Health and Safety Questionnaire Template  A health questionnaire to assess fitness levels and potential risks

SayPro Health and Safety Questionnaire Template

This Health and Safety Questionnaire is designed to assess the fitness levels, medical history, and potential risks for participants in extreme sports activities. The information you provide will help ensure that all participants are fit for the camp activities and to mitigate any potential health risks.

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SayPro Extreme Sports Camp Health & Safety Questionnaire

Please complete this form truthfully and accurately. All information will be kept confidential and used solely to ensure your safety during the camp.

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Personal Information

1. Full Name:
   (First, Last)
2. Date of Birth:
   (MM/DD/YYYY)
3. Phone Number:
   (Mobile or Home)
4. Email Address:

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Emergency Contact Information

5. Emergency Contact Name:
6. Emergency Contact Relationship:
   (e.g., Parent, Spouse, Friend)
7. Emergency Contact Phone Number:

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Health Information

8. Do you have any pre-existing medical conditions?
   (e.g., heart disease, asthma, diabetes, epilepsy, etc.)
   ☐ Yes ☐ No
   If yes, please provide details:
9. Do you take any medication regularly?
   ☐ Yes ☐ No
   If yes, please list the medications:
10. Do you have any allergies?
    ☐ Yes ☐ No
    If yes, please specify:
11. Have you had any of the following conditions in the past year? (Check all that apply) ☐ Heart conditions
    ☐ Respiratory problems (e.g., asthma, chronic cough)
    ☐ Neurological disorders (e.g., epilepsy, vertigo)
    ☐ Joint or bone injuries
    ☐ Mental health concerns (e.g., anxiety, depression, PTSD)
    ☐ Back or spine issues
    ☐ Any recent surgeries or medical treatments
    ☐ None of the above
    If any of the above apply, please provide details:
12. Do you have any physical disabilities or limitations that may affect your participation in physical activities?
    ☐ Yes ☐ No
    If yes, please provide details:

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Fitness and Activity Readiness

13. How would you rate your current fitness level?
    ☐ Sedentary (Little or no exercise)
    ☐ Lightly Active (Exercise 1-2 days/week)
    ☐ Moderately Active (Exercise 3-4 days/week)
    ☐ Very Active (Exercise 5-7 days/week)
    ☐ Extremely Active (High-intensity training regularly)
14. Do you engage in any regular cardiovascular exercises (e.g., running, cycling, swimming)?
    ☐ Yes ☐ No
    If yes, how often?
15. Do you have any injuries, strains, or pain from previous activities that could affect your participation?
    ☐ Yes ☐ No
    If yes, please describe:
16. Have you ever been diagnosed with a condition that affects your balance, coordination, or ability to exercise?
    ☐ Yes ☐ No
    If yes, please provide details:
17. Are you currently pregnant or have you recently given birth?
    ☐ Yes ☐ No
    If yes, please consult your healthcare provider before participating.
18. Do you smoke or have any respiratory issues that may limit your ability to participate in physical activities?
    ☐ Yes ☐ No
    If yes, please explain:

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Extreme Sports Experience

19. Do you have any experience with extreme sports (e.g., skydiving, bungee jumping, zip-lining)?
    ☐ Yes ☐ No
    If yes, please describe your experience:
20. Do you have any fear or anxiety about participating in extreme sports activities?
    ☐ Yes ☐ No
    If yes, please specify:

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Informed Consent for Activities

21. Do you acknowledge that the activities involved in the SayPro Extreme Sports Camp (e.g., bungee jumping, skydiving, zip-lining) carry inherent risks?
    ☐ Yes ☐ No
22. Do you consent to participate in these activities and take full responsibility for any potential risks associated with them?
    ☐ Yes ☐ No
23. Do you agree to inform the SayPro team of any changes to your medical condition or fitness levels before or during the camp?
    ☐ Yes ☐ No

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Additional Notes

24. Is there any other information the camp organizers should be aware of to ensure your safety and well-being during the activities?

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Participant Declaration

I declare that the information I have provided is accurate and complete to the best of my knowledge. I understand that it is my responsibility to inform the camp organizers of any changes to my health or fitness status before or during the camp. I also understand that participation in extreme sports activities carries inherent risks, and I am participating willingly and at my own risk.

Signature of Participant:

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Date:

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For Office Use Only:

• Reviewed by (Staff Member Name): _________________________
• Health Status Reviewed: ☐ Approved ☐ Not Approved
• Additional Notes:

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This Health and Safety Questionnaire is an essential tool to ensure that participants are physically and mentally prepared for the activities involved in the SayPro Extreme Sports Camp. By gathering important health information, the camp organizers can mitigate risks and provide a safe and enjoyable experience for all participants.