Workshop Medical/Diet Form

Please note that this is not a registration form but a diet and medical form for you to fill out after you have registered for an instruction program or a trip.

Name:*

First Last

Email:*

Workshop Name:*

Workshop Dates:*

Your Birthdate:*

Month

Day

Year

Gender:

Male
Female
Prefer Not to Answer

Best number to contact you at:

Best time to contact you:

Anytime is great!
Morning (between 9:00-11am EST)
Afternoon (between 1-5pm EST)
Evening (after 6pm EST)

Emergency Contact Info:

Emergency Contact Name:*

First Last

Relationship:*

Emergency Contact Phone:

Other ways to contact this person:

Health Provider Info:

Canada: Health Card Number:

Other: Provider, Policy #, Contact Info:

Date of last Tetanus Shot:

Recommended every 10 years.

Month

Day

Year

Please describe any medical, physical or mental health conditions that we should be aware of that may affect your participation in this program, including any recent injuries and/or major illnesses:

In the case you require medical attention, please list any regular medications you are taking and for what condition:

Please list any food, drug and environmental allergies (including your reaction and severity if exposed):

Please tell us any dietary restrictions, preferences and dislikes:

What are you most looking forward to with this program and do you have any concerns?