Student Medical Form - Westcoast Adventure College

Contact Details

Name*

First Middle Last

Date of birth*

Gender*

Weight*

Height*

Medical Conditions

ADHD (Attention-Deficit Hyperactivity Disorder)*

Yes

Convulsions / Seizures*

Yes

Hemophilia*

Yes

Asthma*

Yes

Diabetes*

Yes

Heart trouble*

Yes

Please explain any “Yes” answers:

Physical conditions*

Mental health conditions*

Allergies*

Medications (regularly or periodically)*

List any medications taken either regularly or periodically.

Physical or behavioral conditions*

List any physical or behavioral conditions that may affect or limit full participation in backpacking or hiking.

Equipment needed (glasses, contacts, braces etc)

List equipment needed such as, glasses, contact lenses, braces etc

Immunizations

Immunizations, give date of last inoculation.

Tetanus toxoid*

An up to date Tetanus Immunization is required for this program

Dietary

Dietary Requirements / Preferences:

Emergency Contact (First)

Name*

First Last

Relationship*

Phone number*

Mobile number*

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Emergency Contact (Second)

If person named above is not available in the event of an emergency, notify...

Name*

First Last

Relationship*

Phone number*

Emergency Contact (Third) *Optional

If person named above is not available in the event of an emergency, notify...

Name

First Last

Relationship

Phone number

Physician

Name of personal physician

Physician's phone number

Personal health / accident insurance carrier

Policy number

How fit do I have to be to take the course?*

During the course, students will go for full day hikes in challenging terrain, paddle for multiple days in a row and will have to kneel etc for extended periods of time during the first aid course. For this reason students are expected to have a base level of fitness and to maintain that level. Applicants must inform the college of all conditions that could in any way inhibit their participation in classes. Students must also inform instructors in a timely fashion of any injuries that have occurred during the course or other conditions that could affect their participation so that potential alternatives can be sought.

I Read & Understand

How important are my medical details?*

Your medical details are very important. The course is both physically and mentally demanding, and your instructors will need to know as much about you as possible to be able to challenge you without pushing you past your limits. As well as being a physically demanding course, there are several scenarios we use for training purposes throughout the course that are deliberately designed to put pressure on students, so as to allow them to experience dealing with pressure in a controlled environment. Some of these scenarios are also deliberately realistic, and may cause some students difficulty. As we will be out in the field, instructors will need to know of any medical or psychological challenges beforehand so as to adequately prepare for them. If you have omitted any information from your application form please make sure to let us know of any additional information as soon as possible. Failure to disclose any relevant information pertaining to your participation in the course may result in exclusion from the program.

I Read & Understand

Agreement

By typing your name into the field below you agree that all of the information you have provided is true to the best of your knowledge

Please type your full name*

Comments

This field is for validation purposes and should be left unchanged.