Environmental Learning Institute
Confidential Medical History Form for TORCH Educator Courses - Summer, 2007
Please email form to: Dr. David Silverberg firstname.lastname@example.org or fax to: 480-275-3318.
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.
TO THE PARTICIPANTíS HEALTH CARE PROVIDER:
The applicant has applied to participate in a field course with the Environmental Learning Institute.†
The Ladakh, India TORCH courses involve backpack hiking, dayhiking with a 20 pound daypack, hiking on trails and off-trails, traveling in a jeep for several hours on sometimes curvy mountain roads. The elevation of base camp in Leh Ladakh is 12,000 feet and the passes we cross are as high as 18,500 feet. †† Participants will sleep in tents and shared rooms in a simple lodge.
The British Columbia Rainforest TORCH course 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, weíd like to know if you feel the applicant is physically fit to participate in the course.
Health Care Providerís Signature:
MD, CNP, PA (please circle)
Health Care Providerís Printed Name:
Health Care Providerís Phone Number: