MROP 2017: Medical Form

Confidential Medical Form


(PLEASE ANSWER ALL QUESTIONS)

If you have received an acceptance notice for the MROP Program, or if you are registering for the Initiator or the Returning Initiated Men Programs, you must complete the confidential Medical Form.

 

Date of Birth *
Date of Birth
Emergency Contact
Please provide emergency contact information.
Name *
Name
Name of your emergency contact
Your relationship to the emergency contact.
Confidential Questions
Please answer these questions thoroughly and to the best of your knowledge.
Nutritional requirements
Do you have specific food or nutritional requirements?
Do you have or have you had any of the following conditions?
Allergic reactions
Do you have known allergic reactions to any of the following?
Do you have any of the following disabilities?
When walking
If you walked on the level for a mile at an average pace, would you:
Are you taking any prescribed medications at this time?
Physical fitness
Treatment *
Are you currently (or within the pat two years) receiving treatment from a physician or other health care professional for any physical or psychological reason?
Have you ever been told that your SNORING is serious enough that it can disturb others?
Will you have any special medical requirements during the MROP?
Is there anything else you feel we should know regarding your physical or other physical or emotional condition and/or history to help us be of better service to you on your vision quest? Please specify.
Signature
By typing you name in this field you are confirming all the above information is correct.
Today's Date *
Today's Date
Medical release *
By checking this box, I authorize the ILLUMAN DC staff to provide this information to medical professionals providing me emergency care during this event.