Medical Form

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Full Name(required)

Month(required)

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Day(required)

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Year(required)

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Social Security Number(required)

Emergency contact(required)

Telephone 1(required)

Telephone 2

Telephone 3

Emergency contact address(required)

I have medical conditions for which I am under a doctor's care(required)

Yes

No

If yes, please state the condition and the associated doctor's name and contact information in each case

If you have any physical limitations which might need to be taken into consideration, please describe

If you are on a special diet or have food allergies, please describe

If you are allergic to bee stings or insect bites, please specify what medications you normally take

If you will be taking any medications while at Inspiration Point, please list below the names of the medicines and the schedule you will follow in taking them. You are encouraged to bring a plentiful supply as it may be difficult to fill a prescription should you run out.

Month(required)

Select an option January February March April May June July August September October November December

Day(required)

Select an option 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Year(required)

Select an option 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Name and contact info of your GP

Medical insurance policy information

Name of Participant(required)

By checking this box and typing my name below, I am electronically signing this authorization(required)

Signature:(required)

Relationship to Participant(required)

Submit

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