Health Questionnaire

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Please fill out this health questionnaire for participation in a Vision Quest. All information is confidential.

Participant's Full Name *

Pronouns

She

They

Other:

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Date of Birth *

YYYY

Address *

Email Address *

Cellphone *

Program Name and Year *

For example: Weekend Quest June 2023

FOR EMERGENCY USE

Doctor's Name *

Doctor's Phone Number *

Insurance Company + Phone Number *

Insurance Policy Number *

Does your doctor know you are going to participate in this program? *

Yes

In case of emergency, please contact: (first and last name) *

Relationship to emergency contact *

Phone number for emergency contact *

Does your emergency contact know you are participating in this program? *

Yes

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