MROP Medical Form

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The MROP is a wilderness event involving sleeping outdoors in a tent in a remote area, moving over level but uneven ground, and a brief period of fasting. With this in mind, please complete this form as accurately as possible and please reach out with any questions! All staff and participants are required to provide proof of COVID-19 vaccination. Thank you.

    First Name

    Last Name

    Email

    Cell Phone

    Birthdate

    Height

    Weight

    Age

    I am registering as:

    COVID-19 Vaccination:
    According to the CDC, people are considered fully vaccinated:
    2 weeks after their second dose in a 2-dose series, such as the Pfizer or Moderna vaccines, or
    2 weeks after a single-dose vaccine, such as Johnson & Johnson’s Janssen vaccine

    Have you been fully vaccinated for COVID-19?

    Vaccination details and dates

    Do you use a CPAP machine?

    Please list any food allergies or dietary needs:

    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 diagnosis/treatment:

    Are you taking any medications at this time?

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

    Do you have any allergic reactions to any insects bites/stings, environmental substances or medications?

    If yes, please explain allergic reactions:

    How would you rate your current level of physical fitness?

    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

    Emergency contact (Full Name):

    Relationship:

    Address (street, city, state, zip):

    Cell phone (primary):

    Home phone:

    Other phone:

    Health Insurance:

    Health insurance company:

    Group Number:

    Policy Number:

    Insurance company phone number:

    Signature:

    By typing your name above you are confirming all the information above is correct.