MROP Medical Form

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Please complete this form as accurately as possible.  Thank you.

    First Name

    Last Name

    Email

    Cell Phone

    Birthdate

    Occupation

    Height

    Weight

    Age

    I am registering as:

    Do you wear a medical alert bracelet?

    If yes, for what medical condition?

    Do you use a CPAP machine?

    Have you ever had a heart attack?

    If yes, when, and your heart condition now:

    Check any of the following conditions you have or are bring treated for:
    High blood pressureHeart murmurHeart DiseaseNone

    Please list your blood pressure and resting heart rate if you know it:

    Do you have any known allergies or sensitivities to insect bites or stings that could result in anaphylactic shock?

    If yes, please explain allergic condition:

    Do you have any allergic reactions to any environmental substances, food or drugs?

    If yes, please explain allergic reactions:

    Are you hypoglycemic or diabetic?

    If yes, please specify:

    Have you ever experienced a seizure of any kind?

    If yes, please provide details of the seizure:

    Do you have hemophilia?

    Do you have any disabilities of the back, knees, hips or ankles?

    If yes, please clarify limiting condition:

    Have you ever had lung disease (asthma, emphysema, etc.?

    If yes, please explain your respiratory condition:

    If you walked on the level for a mile at average pace, would you get out of breath, have chest pain or leg pain, or develop muscle fatigue?

    If yes, your walking condition:

    What was the date of your last tetanus shot?

    If you're not sure of date put approximate. If never, enter None.

    How would you rate your current level of physical fitness?

    Are currently (or within the past two years) receiving treatment from a physician or other health care professional for any physical or psychological reason?

    If yes, please explain your treatment:

    Are you taking any medications at this time?

    If yes, please specify medication, dosage, and the reason for which it was prescribed:

    Is there anything else you feel we should know regarding your physical/emotional condition and/or history to help us be of better service to you on your MROP?

    If yes, please explain:

    Emergency Contact

    First emergency contact (Full Name):

    Relationship:

    Address (street, city, state, zip):

    Cell phone (primary):

    Home phone:

    Other phone:

    Optional, but a good idea:

    Second emergency contact (Full Name):

    Relationship:

    Address (street, city, state, zip):

    Cell phone:

    Home phone:

    Other phone:

    Health insurance company:

    Group Number:

    Policy Number:

    Insurance company phone number:

    Release Of Liability (read and sign electronically below)

    In consideration for participating in this Men's Rites of Passage (MROP) on May 15-19, 2019 at Skalitude Retreat Center, and in full recognition and appreciation of the dangers and risks inherent in such activities, I do hereby waive, release, and forever discharge Illuman, Illuman of WA, Skalitude Retreat Center, their officers, agents and employees, as well as any associated persons from and against any and all claims, demands, action or causes of action for costs, fines, expenses or damages to personal property or personal injury, or death, which may result from my participating in these activities.

    I understand that all costs for emergency medical treatment, should it be necessary, including medical transportation via ground or air, are my sole responsibility.

    I understand and admit that my participating in this event is voluntary. I assume full responsibility for any injuries or damages resulting from my participating in this event including responsibility for using reasonable judgment in all phases of participating in the event and travel to and from the event’s location.

    I affirm that I am in good health. I further declare that I am physically fit and capable to participate in such activities. I acknowledge the risk that I am taking in participating in this event. I understand that it is my responsibility to notify the appropriate person at the event location of emergency medical information.

    I also understand that this Waiver of Liability and Release binds my heirs, executors, administrators, and assignees, as well as myself.

    Signature:

    By typing your name above you are confirming all the information above is correct and acknowledging your acceptance of the conditions outlined above. This form will be at the registration table as you check-in for your "wet" signature.