Medical Information and Emergency Contact Form

Participant name: *

First Name

Last Name

Please check any of the following items that apply to you: *

Allergies

Anxiety

Asthma

Back pain/prior injury

Convulsions, seizures, epilepsy

Depression

Diabetes

Dietary Restrictions

Eating Disorder

Eye or ear problems

Faintness or shortness of breath

Headaches/Migraines

Heart disease, chest pains, murmur, etc.

Hypoglycemia

Infectious hepatitis, meningitis, etc.

Menstrual Complications

Previous broken bones

PTSD

Other not listed

None of the above apply to me

Do you require wheelchair assistance for the airports? *

Yes

No

Date of last doctor's visit *

MM

DD

YYYY

Emergency Contact #1 *

First Name

Last Name

Emergency Contact #1 Phone *

(###)

###

####

Emergency Contact #2 *

First Name

Last Name

Emergency Contact #2 Phone *

(###)

###

####

By checking this box I understand that I need to inform Compass of any pertinent changes (injuries, medications, allergies etc.) that happen between the submission of this form and the start of the program. I understand that if I choose not to do so, Compass may not be able to fully accommodate me. *

I will inform Compass of any pertinent changes to my medical information.

Your Electronic Signature *

First Name

Last Name