First Name
*
Last Name
*
Address 1
*
Address 2 (optional)
City
*
State/Province
*
Zip/Postal Code
*
Country
*
Email Address
*
Phone
*
Best Time to Call
*
Anytime
After 5pm
8am - 5pm
I prefer email
Date of Birth
*
MM
DD
YYYY
Contact First Name
*
Contact Last Name
*
Primary Phone
*
Secondary Phone
Height
Weight
Nutritional requirements
Do you have specific food or nutritional requirements?
Vegetarian
Gluten free
Lactose intolerant
OTHER
If you checked any of the above, please comment:
Do you have or have you had any of the following conditions?
Epilepsy/seizures
Bleeding/clotting disorder
Heart attack
Heart disease
Heart murmur
Stroke
Asthma
Emphysema
High blood pressure
Diabetes
Hypoglycemia
Lung disease
Seizures of any kind
OTHERS we should know about
None
If you checked any of the above or answered OTHER - describe your conditions below:
Allergic reactions
Do you have known allergic reactions to any of the following?
Environmental substances
Foods
Drugs
Sensitivity to insects
Sensitivity to stings / anaphylactic shock
If you checked any of the above, please comment:
Do you have any of the following disabilities?
Back
Knees
Hips
Ankles
OTHER
If you checked any of the above, please comment:
When walking
If you walked on the level for a mile at an average pace, would you:
Get out of breath
Have chest pain
Have leg pain
Develop muscle fatigue
OTHER
If you checked any of the above, please comment:
Are you taking any prescribed medications at this time?
Yes
No
If yes, for each please list condition, medication and dosage, e.g. High blood pressure, Lisinipril, 40 mg. daily
Physical fitness
Excellent
Good
Average
Fair
Poor
Treatment
*
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
No
If you answered YES above, please describe:
When did you have your last tetanus shot?
Have you been FULLY vaccinated and boosted for COVID19
*
Yes (2 Doses)
No
Have you ever been told that your SNORING is serious enough that it can disturb others?
Yes
No
Will you have any special medical requirements during the MROP?
Yes
No
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.
Today's Date
*
MM
DD
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
Text Area
PROOF OF BEING FULLY VACCINATED FOR COVID19 IS REQUIRED FOR ALL PARTICIPANTS – NO EXCEPTIONS
Submit a photo of you COVID19 Vaccination Certificate to: admin@illumandc.org by April 1, 2022.