Health Information

Please fill out the following form in order to complete your registration process and participate in our program.

First Name

Last Name

Date of Birth

Do you have any dietary restrictions (as opposed to preferences)

Yes

If yes, please elaborate on your dietary restrictions

Height

Weight

Please list your resting pulse rate if you know it.

Please list the date of your most recent tetanus shot:

Is there anything else you feel we should be aware of regarding your physical/emotional condition and history to help us be of better service to you?

Emergency Contact #1

Please list your emergency contacts' name, relationship to you & cell phone number.

Emergency Contact #2

Please list your emergency contacts' name, relationship to you & cell phone number.

•Please note that in the United States it is essential to have your own health insurance. If you are an American, please ensure that you do so. An emergency room visit can cost up to $4,000 while an overnight hospitalization may cost close to $10,000 USD. •If you are a visitor from another country, please consider obtaining travel insurance from your own country to cover any expenses related to the exorbitant US health care system costs.

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!