Paths of Courage Application Form Step 1 of 4 25% Personal InformationName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Primary Telephone NumberCan we leave a message ? Yes No Alternative Telephone NumberCan we leave a message ? Yes No Email Have you visited a Hospital Emergency Room in the last year? Yes No How many times? General Information - Part 1*NOTE* This information is considered private and confidential and will be used only for the purposes of medical assessment for the participation on a course with The Sexual Assault Centre for Quinte and District’s Paths of Courage Healing Program. EACH PARTICIPANT IS RESPONSIBLE FOR ANY MEDICAL EXPENSES, INCLUDING MEDICAL EVACUATION, AND MUST BE COVERED BY THEIR OWN MEDICAL AND ACCIDENTAL INSURANCE.Do you have provincial medical coverage? Yes No Provincial Health Card Number:ProvinceIf the Applicant does not have provincial medical coverage, please indicate private or alternate medical insurance information below and attach a photocopy of your policy information.Insurance CompanyPolicy NumberExpiry DateGroup NumberAddressPhonePart II: Medical HistoryName First Last Give a brief statement of your general healthHeightWeightPrimary Care Physician First Last Primary Care Physician PhoneDo you have any present medical conditionsYesNoDetailsAre you taking any medicationsYesNoListMedication NameCondition TreatedDosageSchedule Have you had any surgeries?YesNoDetails Do you suffer from any allergiesYesNoAllergiesAllergenNature of ReactionSeverity Do you carry an epi-pen for you allergiesYesNoDetailsDo you smoke or use tobacco products?YesNoDetailsHave you had or do you currently have a substance abuse problem ? (alcohol, drugs etc...)YesNoDetailsDo you have a personal or family history of cardiovascular disease or conditions?YesNoDetailsDo you have a history of high blood pressure or hypertension?YesNoDetailsDo you have asthma?YesNoDetailsHave you had or do you have ulcers or other significant stomach/intestinal problems?YesNoDetailsDo you have any eating disorders: anorexia, bulimia, etc.?YesNoDetailsDo you have hepatitis?YesNoDetailsDo you have any bleeding problems or blood disorders?YesNoDetailsDo you have diabetes, hypoglycemia, thyroid or endocrine conditions?YesNoDetailsDo you have chronic bladder infections/problems, difficulty urinating, bedwetting?YesNoDetailsDo you have a seizure disorder?YesNoDetailsDo you suffer from a sleep disorder (ex. sleep apnea)?YesNoDetailsDo you suffer from severe headaches, dizziness, or fainting?YesNoDetailsHave you ever had a brain injury requiring treatment?YesNoDetailsDo you have problems with your neck, back, arms or legs that limit your activity?YesNoDetailsDo you have problems with vision or hearing?YesNoDetailsDo you have chronic skin problems (ex. rashes, sun sensitivity, etc.)?YesNoDetailsHave you ever suffered from heat exhaustion or had significant reactions to heat?YesNoDetailsDoes your health prevent you from participating in any physical activities?YesNoDetailsDo you have any communicable diseases?YesNoDetailsFor Females: Are you pregnant?YesNoDetailsDo you have a learning disability?YesNoDetailsHave you ever been to a psychiatrist, psychologist, therapist, or counselor?YesNoAre you currently in treatment?YesNoDetailsHave you been under treatment within the last two years?YesNoDetailsReason for treatment Sexual Abuse Family Issues Behavioural Disorder Psychiatric Hospitialization Substance Abuse Relationship Issues Eating Disorder Self Harm Post Traumatic Stress Disorder Attention Deficit Disorder Mood / Anxiety Disorder Other Name of therapist/counselor so we may contact: First Last Therapist/counselor Telephone:What is your swimming ability?Non-SwimmerCan swim 100m without lifejacketStrong Swimmerit is strongly recommended that ALL participants be able to swim at least 100 metres.Are you comfortable (ex. will not panic) in deep water while wearing a lifejacket or PFD?YesNoPlease describe in detail what you do routinely to maintain an active lifestyle (mention activities and frequency.) PATHS OF COURAGE COMMITMENT CONTRACTName* First Last Date* Signature*CAPTCHA It will never become difficult to pass through click this here now the michael kors handbags for sale with luxury bags.
