Are you currently (or within the pat two years) receiving treatment from a physician or other health care professional for any physical or psychological reason?

Yes

If you answered YES above, please describe:

When did you have your last tetanus shot?

Have you ever been told that your SNORING is serious enough that it can disturb others?

Yes

Check here if you need an electrical outlet for a breathing a CPAP or other breathing device.

Will you have any special medical requirements during the MROP?

Yes

If you answered YES above, please describe:

Additional comments

Is there anything else you feel we should know about you (your history or any other physical or emotional conditions) to help us be of better service to you during your time with us? Please specify.

Signature

Signature *

By typing your name in this field you are confirming all the above information is correct.

Today's Date *

YYYY

Medical release *

By checking this box, I authorize the ILLUMAN DC staff to provide this information to medical professionals providing me emergency care during this event.

Yes, I authorize ILLUMAN DC to release this medical information

Thank you for submitting the medical form!

MROP 2024: Medical Form

Confidential Medical Form

(PLEASE ANSWER ALL QUESTIONS)

If you have received an acceptance notice for the 2025 EROP Program, you must complete the confidential Medical Form.

If an update is required after initial submission of either form, please contact the EROP Registrar directly.

Illuman East Coast Region
Convener: Jim Burns
Co-Convener: Kevin Barwick
Immediate Past Convener: Dan Harris

Convener Emeritus: John Ball
Contact Us via Email: admin@illumandc.org

Virtual Council held the second and fourth Tuesday each month, 8:00 to 9:30 P.M. ET
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