Paths of Courage Application Form

Personal Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Primary Telephone Number
Can we leave a message ?
- Yes
- No
Alternative Telephone Number
Can 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:
Province
If 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 Company
Policy Number
Expiry Date
Group Number
Address
Phone
Part II: Medical History
Name
First Last
Give a brief statement of your general health
Height
Weight
Primary Care Physician
First Last
Primary Care Physician Phone
Do you have any present medical conditions
- Yes
- No
Details
Are you taking any medications
- Yes
- No

List

Medication Name	Condition Treated	Dosage	Schedule

Personal Information