Health Information, Medical History, Permission to Allow Treatment, and Health Waiver
* Denotes Required Field.
Medical History
I am taking a prescription.
Yes
No
Hearing/sight problems
Yes
No
Fainting Spells/Convulsions/Epilepsy
Yes
No
Neck or Back Injury
Yes
No
Asthma
Yes
No
High Blood Pressure/Abnormal EKG/ Coronary Heart Disease/ Other Heart Problems
Yes
No
Kidney Problems/Bladder Infections
Yes
No
Hernia
Yes
No
Diabetes
Yes
No
Eating Disorder
Yes
No
Allergies
Yes
No
Depression
Yes
No
I am currently under the care of a physician.
Yes
No
If response to the above question is yes, add condition and type of treatment.
Head Injury (concussion, skull fracture)
Yes
No
For women: Are you pregnant?
Yes
No
My blood type is
Do you have any other health concern that we should be aware of?
Please identify any medical or health experience that you have (First Aid certification, medical degrees, Emergency Medical Technician, etc)
Would you be willing to use your medical/health knowledge and skills during the field-based course if called upon?
Yes
No
Explanation
Name
Please read carefully and Submit
In the event of sickness or injury of myself, I hereby authorize the Future Generations faculty member or leader in charge during the field-based course to secure whatever treatment is deemed necessary, including the administration of an anesthetic and surgery or similar invasive procedure.
I accept full financial responsibility for any medical costs incurred during the field-based course. I understand that the University will provide travel medical insurance for the
field-based course
periods, but that this is subject to a deductible and will not necessarily cover all medical expenses incurred.
I understand the rigor of this Master’s program and my responsibility for consulting the CDC website for health alerts and travel advisories for the countries to which I am traveling. I am responsible for obtaining immunizations based on the travel itinerary, for acting in accordance with the advice of my own physician, for taking any necessary precautions based on my own medical history, and for tending to any special dietary needs that I have. Furthermore, I do not hold Future Generations and its faculty/staff members liable for their due diligence in offering this Master’s program.
I understand that if I fail to provide correct and accurate information that my health in the field could be jeopardized. I acknowledge that the information I have provided is complete and accurate to the best of my knowledge. If my health or this information changes in the course of the Master’s program, I will inform University administration.
Acknowledgement
Name
*
Provide your email address to receive acknowledgement email along with the copy of this filled form.
Declaration
*
I agree that by Checking this box and submitting this form that all information is accurate to the best of my knowledge.
Personal Information
Work Telephone
Name
*
Birth Date
*
Age
*
Address
*
Telephone
*
Email
*
Identification Number
Passport Number
Emergency Contact Information
*
Relationship
Address
Home Telephone
Email
Insurance Information (if applicable)
Insurance Company
Policy/Subscriber
Group
Health Information
Physician's Name
*
Telephone
*
Address
*
Email
Submit
