Please complete the form below in full. The more information you provide, the more we can care for you during the program. Failure to disclose pertinent medical information to Compass may result in injury or mishap otherwise preventable.

All information provided on this form is confidential and will be viewed only by Compass staff.

Compass requires two emergency contacts for every participant. Emergency contacts can not also be trip participants.

NOTE: By signing your name electronically at the end of this form, you agree that your electronic signature is the legal equivalent of your manual signature. If the participant is under the age of 18, a parent/guardian should be the one to fill out and sign this form.

Compass Medication Policy

Compass requires that participants disclose any and all regular prescriptions, over-the-counter meds, vitamins or supplements being taken while on the program on this medical form.

In order for a participant to use prescribed medication during Compass, they must ensure they are storing the medication in the original container with a pharmacy label identifying name, drug, dosage (be specific), time medication should be given and physician’s name. If not stored in the original container (i.e. in a pill distributor or planner), participants are asked to carry a copy of the prescription.

All participants aged 18 and older will carry and self-administer their medications. A program leader will carry and administer all medications for any participants aged 17 and younger.

All participants need to inform Compass of any pertinent changes (injuries, medications, allergies etc.) to their medical information that happen between the time the form was submitted and the start of the trip.

Participant name: *

First Name

Last Name

Your email: *

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

Please explain any checked boxes. The more information we have, the more helpful it is to us in keeping you safe and cared for on the trip. *

If you didn't check any boxes, please put "N/A"

Allergies. Please include the severity and symptoms of an allergic reaction, as well as course of treatment for each. *

If you have none, please put "N/A"

Dietary Restrictions and Instructions (if any): *

Please include food allergies/intolerances. If you have none, please put "N/A"

Current medications (include dose and frequency of anything you will be taking while on the Compass trip- this includes all prescriptions, OTCs, vitamins and supplements): *

If you have none, please put "N/A"

Are you currently pregnant? *

If yes, how far along will you be during the Compass program? Note: If you will be in your third trimester, you will need approval from a doctor prior to travel. If you are not pregnant, please put "N/A"

Do you carry an epi-pen or inhaler? If yes, please specify. *

Please note: Compass requires that any participants who need either an epi-pen or an inhaler bring a minimum of two that they will keep on their person at all times during the program. If you do not need an epi-pen or inhaler, please put "N/A"

Do you require wheelchair assistance for the airports? *

Yes

Are there any other things we should know about you that will be important for us to provide you the support you need on this trip? *

Mental health, physical health, mobility limitations, special requirements for medication storage etc.

Date you received your most recent flu vaccination: *

If you have never received a flu vaccination, please put "N/A"

Date of last doctor's visit *

YYYY

Purpose of visit if general or prefer not to answer, leave blank)

Emergency Contact #1 *

First Name

Last Name

Relationship to you *

Emergency Contact #1 Phone *

(###)

###

####

Emergency Contact #1 Email *

Emergency Contact #2 *

First Name

Last Name

Relationship to you *

Emergency Contact #2 Phone *

(###)

###

####

Emergency Contact #2 Email *

Over the Counter Medications

Compass carries OTCs for common ailments such as pain relief, stomach upset, motion sickness etc. These OTCs will be administered to participants on an as needed basis according to the manufacturer's instructions. If the participant is under the age of 18 please indicate below any OTCs that you do NOT wish Compass to administer to them. If none, or if the participant is over the age of 17, please put "N/A."

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

Your Electronic Signature *

First Name

Last Name

Thank you for submitting your Compass medical form!

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call or text: 978.646.7926

PO Box 274, Wenham, MA 01984