Photo by Kerry Brady

Health & Emergency Form

We look forward to journeying with you and want to make sure you are safe and comfortable in every way.
Please fill out the below form in order to complete your registration.

Note: If you prefer to fill the form out offline, please fill out this PDF version and snail mail it to:
Kerry Brady, 1210 Furlong Rd, Sebastopol, CA, 95472.

Name *
Name
Phone *
Phone
Birthdate *
Birthdate
Does your emergency contact person know you are participating in this program? *
Are you under the care of a physician? If so, please describe: *
Do you wear a Medic-Alert Tag or any other marker of a medical problem? If yes, please describe: *
Were you hospitalized in the last two years? If yes, please describe: *
Have you ever had a heart attack of any kind, or been told by a doctor that you have high blood pressure, a heart murmur or heart disease? If yes, please describe: *
Have you ever had a seizure of any kind? If yes, please describe: *
Are you allergic to environmental substances, foods, drugs, insect bites or stings? Have you ever had an anaphylactic (severe allergic) reaction to any of the above? If yes, please describe: *
Do you have hemophilia or any other disorder that impairs blood-clotting? If yes, please describe: *
Do you have a lung disease or any kind of breathing problem? If yes, please describe: *
Do you have any muscle, joint, or bone related disabilities? If yes, please describe: *
Do you have a history with migraines or severe headaches? If yes, please describe: *
Do you have any kidney disease? If yes, please describe: *
If you walked a level mile at an average pace would you get out of breath, have chest or leg pains or develop muscle fatigue?
Do you have documented hypoglycemia or diabetes? If yes, please describe: *
Do you have any other chronic or acute condition that, in any way, threatens your health? If yes, please describe: *
Are you taking any medication at the present time? If yes, specify each drug, the dose and the reason for taking: *
This information is accurate and complete. I agree to cooperate with the Ecology of Awakening guides with full consideration of my health history and health concerns *
Date *
Date