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Pe.tfs.ca

ME TO WE TRIPS
HEALTH FORM
PARTICIPANT NAME
Please fill out the medical information below clearly and completely. This form is meant as a means to better accomodate the needs of our participants and is not used as part of the acceptance process. All information provided in this form will be kept strictly confidential by Me To We Trips, except as otherwise stated in this form. Medical information provided below may also be used or disclosed by Me To We Trips if required for the provision of medical care while on the trip or for meal planning purposes. This health form must be signed by a
registered physician in order to be accepted on a Me to We Trip.
Do you have any life-threatening allergies? YES If yes, please explain allergy and history of reactions.
Do you have any non-life-threatening allergies? YES If yes, please explain allergy and history of reactions.
Past/Current Illnesses
Please check all applicable boxes and provide the date of the condition. If more space is needed, please attach additional information to the back of the form. Do you have any dietary restrictions? YES Vaccinations
Please provide the date of your most recent vaccinations for the following: Physical and Emotional Condition
Given the group nature of Me To We Trips programs, please explain how well-equipped you are to be in a group environment for an extended period of time.
Please provide any examples that would illustrate your ability to work well in a group for an extended period Have you ever been involved in pyschological theraphy of any kind? Are you currently involved in pyschological theraphy of any kind? YES Do you occasionally use any substances (including cigarettes, alcohol, or narcotics)? Do you have a history of addiction and/or substance abuse (including cigarettes, alcohol, or narcotics)? YES Me To We Trips are often physically strenuous and require physical fitness on the part of the participants. Please rate your physical fitness on a scale from 1 - 10 (1 = very unfit and 10 = extremely athletic). Please provide some examples of your current physical fitness (i.e., participation in sports, dance, etc.).
Medications
Please list all medications (over-the-counter and prescription) that you are currently taking and/or will be taking on the trip. All medication sent on the trip must be in its original container and must be labelled with your name. Medications taken to the camp that are not listed will not be administered. Attach additional pages as needed.
___ Participant takes NO medication on a routine basis and NO medications will be sent with this person.
___ Participant takes medications as follows: Medication__________________________________ used for______________________________Amount/dosage______________________________when taken____________________________ Medication_________________________________ used for_______________________________Amount/dosage______________________________when taken____________________________ Medication__________________________________ used for______________________________ Amount/dosage______________________________when taken____________________________ Medication_________________________________ used for_______________________________ Amount/dosage______________________________when taken____________________________ Are there any special circumstances we should know about regarding your medical care (i.e., cultural or Treatment
Me To We Trips facilitators have standard first aid training. An extensive first aid kit is available at all times and contains standard over-the-counter remedies for common ailments. The following is a list of medications that we have available at the camp. Please indicate each of the medications you may or may not be given should the Sunburn relief sprayAntiseptic (Neosporin)Ear dropsCough drops (Robitussin)Sore throat sprayMilk of MagnesiaAnti-diarrhealCalamine lotionPenicillinIbuprofenTylenolCough dropsDecongestantAntihistamine (Benadryl)Burn gelAntacids (Tums) Insurance Information

Policiy or Group #
Legal Waiver
The undersigned acknowledge that we have read and understand the information in the “Me To We Trips Medical History Form” and that all of the information provided above is correct and all information regarding the participant’s physical and emotional health has been disclosed. We understand that failure to provide accurate disclosure could, at Me To We Trips’ sole discretion, result in the participant being sent home immediately at the expense of the participant or his/her parent/legal guardian. By signing below, the signatories also commit to updating Me To We Trips if any of the participant’s medical information changes prior to the departure of the If participant is under the age of 18, signature of his/her parent/legal guardian Acknowledgement by Participant’s Physician
I, the undersigned, am the participant’s physician and I hereby acknowledge that I have carefully read the disclosure provided in the “Me To We Trips Medical History Form” and such disclosure is, to the best of my knowledge, a true and accurate reflection of the participant’s physical and emotional health.
DATE

Source: http://pe.tfs.ca/resources/overnight_trips/Group%20Trips%20Part%202%20-%20health%20forms.pdf

Pii: s0166-3542(98)00015-

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