Educate Wild Medical History Template printable pdf download

Revised F ebruary 2 016

E ducate W ild! M edical H istory T emplate

PROGRAM N AME

This D ocument H as L egal C onsequences. I t M ust B e C ompleted A nd S igned P rior T o P articipation.

Please R ead I t C arefully B efore S igning.

(Please P rint)

Participant’s N ame: _ __________________________________________ D ate o f B irth: _ ____ / ____ / _____

Email: _ ______________________________________________________ P hone: _ _____________________

Permanent A ddress: _ _______________________________________________________________________

Height: _ _______________________ Weight: _ ________________

Gender: _ ____________________

Emergency C ontact I nformation

Emergency C ontact # 1 N ame: _ ________________________________________________________________

Address ( town, s tate): _ ________________________________ R elationship t o p articipant: _ ______________

Cell P hone: _ ___________________________________ O ther P hone: _ _______________________________

Does t his p erson s peak a nd r ead E nglish? Y es / S ome / N o

If n o, w hat i s t heir p rimary l anguage? _ __________________________________________________________

If n ot, w ho c an f acilitate c ommunication w ith t his p erson i n t he e vent t hat y ou a re n ot a ble t o d o s o?

__________________________________________________________________________________________

Emergency C ontact # 2 N ame: _ ________________________________________________________________

Address ( town, s tate): _ ________________________________ R elationship t o p articipant: _ ______________

Cell P hone: _ ___________________________________ O ther P hone: _ _______________________________

Does t his p erson s peak a nd r ead E nglish? Y es / S ome / N o

If n o, w hat i s t heir p rimary l anguage? _ __________________________________________________________

If n ot, w ho c an f acilitate c ommunication w ith t his p erson i n t he e vent t hat y ou a re n ot a ble t o d o s o?

__________________________________________________________________________________________

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a nd s ee

E ducate-‐

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Educate Wild Medical History Template