Environmental Learning Institute Confidential Medical History Form for TORCH Educator Courses - Summer, 2005 Please mail form to: Dr. David Silverberg, ELI, PO Box 3727, Tucson, AZ 85722 USA or fax to: 480-275-3318. Participant’s Name: Course Title: Course Dates: Because of the physical nature of some of the course activities it is important for the staff to be informed of all medical conditions of the potential program participant. If you have had any of the following conditions or are currently experiencing them, circle the number and give details below. For any circled conditions, please have your health care provider directly address the condition in their approval for your participation in the course. All information presented in this form will remain confidential.
If you circled any of the above items, please list details below according to item number. Be specific (include dates, names of meds, etc.). Use back of sheet if needed. Participant Signature: Date: TO THE PARTICIPANT’S HEALTH CARE PROVIDER: The applicant has applied to participate in a field course with the Environmental Learning Institute. The Belize and Maya Coast TORCH courses involve hiking, dayhiking with a 20 pound daypack, hiking on trails and off-trails, traveling in a van for several hours on sometimes curvy coastal roads, traveling in a motorboat on a choppy water surface, snorkeling for several hours a day. Participants will sleep in shared rooms in a simple lodge. The British Columbia Rainforest, InsidePassage/Yukon, Alaska Range and Brooks RangeTORCH courses involve hiking in the forest and tundra, dayhiking with a 20 pound daypack, hiking on trails and off-trails, traveling in a van for several hours on sometimes curvy coastal and mountain roads, traveling in a motorboat on a choppy water surface. Participants will sleep in tents, in sleeping bags with sleeping pads on the ground. Based on the inherent nature of field work, we’d like to know if you feel the applicant is physically fit to participate in the course. Please comment: Health Care Provider’s Signature: MD, CNP, PA (please circle) Date: Health Care Provider’s Printed Name: Health Care Provider’s Phone Number: |