2018 WUFC Personal Medical Assessment

Please provide the following information to assist with planning & logistics. We understand this information is very sensitive. Completed forms are held in strict confidence and are given only to emergency responders in the event that you are unable to do so yourself. All forms are destroyed at the end of camp.

Before you begin, please collect the following information:
- Medical Insurance carrier, policy number, and contact phone number
- Any Health & Safety training (e.g., CPR/AED) courses you've completed and approximate dates of completion
- A list of all medications you take regularly, including name of drug(s), dosage(s), & times you normally take them.
- Information on any dietary restrictions and known allergies
- Details associated with any preexisting medical conditions

Unless otherwise indicated, all fields are required – do not leave blanks. If a field is inapplicable to you, please clearly indicate with “n/a.”

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