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: 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 PhonePart II: Medical HistoryName First Last Give a brief statement of your general healthHeight Weight Primary Care Physician First Last Primary Care Physician PhoneDo you have any present medical conditions Yes No DetailsAre you taking any medications Yes No ListMedication NameCondition TreatedDosageSchedule Have you had any surgeries? Yes No Details Do you suffer from any allergies Yes No AllergiesAllergenNature of ReactionSeverity Do you carry an epi-pen for you allergies Yes No Details Do you smoke or use tobacco products? Yes No Details Have you had or do you currently have a substance abuse problem ? (alcohol, drugs etc...) Yes No Details Do you have a personal or family history of cardiovascular disease or conditions? Yes No Details Do you have a history of high blood pressure or hypertension? Yes No Details Do you have asthma? Yes No Details Have you had or do you have ulcers or other significant stomach/intestinal problems? Yes No Details Do you have any eating disorders: anorexia, bulimia, etc.? Yes No Details Do you have hepatitis? Yes No Details Do you have any bleeding problems or blood disorders? Yes No Details Do you have diabetes, hypoglycemia, thyroid or endocrine conditions? Yes No Details Do you have chronic bladder infections/problems, difficulty urinating, bedwetting? Yes No Details Do you have a seizure disorder? Yes No Details Do you suffer from a sleep disorder (ex. sleep apnea)? Yes No Details Do you suffer from severe headaches, dizziness, or fainting? Yes No Details Have you ever had a brain injury requiring treatment? Yes No Details Do you have problems with your neck, back, arms or legs that limit your activity? Yes No Details Do you have problems with vision or hearing? Yes No Details Do you have chronic skin problems (ex. rashes, sun sensitivity, etc.)? Yes No Details Have you ever suffered from heat exhaustion or had significant reactions to heat? Yes No Details Does your health prevent you from participating in any physical activities? Yes No Details Do you have any communicable diseases? Yes No Details For Females: Are you pregnant? Yes No Details Do you have a learning disability? Yes No Details Have you ever been to a psychiatrist, psychologist, therapist, or counselor? Yes No Are you currently in treatment? Yes No Details Have you been under treatment within the last two years? Yes No Details Reason 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-Swimmer Can swim 100m without lifejacket Strong Swimmer it 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? Yes No Please describe in detail what you do routinely to maintain an active lifestyle (mention activities and frequency.) PATHS OF COURAGE COMMITMENT CONTRACTName* First Last Date* DD slash MM slash YYYY Signature*CAPTCHA Δ It will never become difficult to pass through click this here now the michael kors handbags for sale with luxury bags.
