Upenn Recreation

Injury/Accident Report


Individual(s) Involved

*Include guest sponsor information as well.


Release Signature: Refusing Attention:

I have been advised that I may have a medical condition, which may require an examination by a doctor, and I refuse such medical care and/or advice that has been rendered by the Campus Recreation personnel, OR I do not believe a medical emergency exists and I require no further assistance.

Hours of Operation

For Monthly Updates:

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