Application and Participant Health Record

  1. Participant Name: _______________________________ Date of Last Physical: _______________
  2. Birth date:      Age: _______     Height:  _______     Weight:  _______     BP: _____________
  3. Allergies (meds, food, etc.) _____________________________________________________________
  4. Pertinent Past History (Illnesses, Surgeries, and Injuries):                                                                                                                                                                                    
  5. Chronic Illness:
  6. Vision: R 20/____ L 20/___       □ Color blind        □ Glasses            □ Contacts
  7. Hearing R      L                      Aid? _____________________
  8. Check (P) the following if you have issues, and comment below:

□ Skin diseases                 □ Diabetes                         □ Chronic Infections

□ Orthopedic issues          □ Back problems               □ Neurologic problems

□ ENT – hayfever              □ Head/Neck issues          □ Seizure disorders

□ Lungs – asthma              □ Heart problems

  1. Comments:  
  2. Current medications:
  3. Other health issues: _________________________________________________________________
  4. Address: ________________________________; Phone:____________; email:___________________

Physical Requirements:

There will be at least three significant hikes involved in the clinics served by Project Belize 2017. Participants are likely to participate in one or more of these. These hikes are often through muddy, unimproved trails through the rain forest including a number of significant hills and river crossings with little to no shade. Temperature and humidity are routinely in the 90’s. The issue of personal fitness matching the needs of the hikes is important in ensuring no one is hurt as this could detract from the mission of the group and put oneself and others in harm’s way. Consider a typical hike to include walking across uneven and muddy terrain up and down hills in 90 plus degree heat with 90 plus humidity, carrying a 15 to 20 lb pack for up to 3 hours. If this gives you pause, you should explore other opportunities.

I attest that I am able to meet the criteria set for Vigorous activity+, Greater than 6.0 METs* (more than 7 kcal/min) as noted in the attached link as defined by the CDC.

http://www.cdc.gov/nccdphp/dnpa/physical/pdf/PA_Intensity_table_2_1.pdf  

Participant’s full printed name will serve as signature:                                   ___________Date:_______

 

In Case of Emergency Notify:

Name:                                                                                                  , relationship:_____________

Address:                                                                                             

Phone number:                                                                                   

Add a page describing your past experience in strenuous physical activities and your interest in being a part of Project Belize, 2018.