2024 CWCC Questionnaire (Medical/ Private/Sealed)

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This will be Kept in a Sealed envelope in the Crew med kits in case of emergency

Name (First and last) *

Medication Taken Daily *

Please Let us know if there is any medication you take daily. This will be your responsibility to bring on spike, but incase of medical emergency it is important we know this information

Allergies, Environmental Sensitivities, Medical Conditions *

If you have any serious allergies food or non-food, Environmental Sensitivities (i.e., a particularly bad reaction to poison ivy) or pertinent medical conditions, we would appreciate it if you let us know below. This will be kept in a sealed envelope and not opened unless, A medical situation arises. We respect your medical privacy. If you want Crew Leadership to be made aware of this ahead of time please tell us. If none, please write N/A

Emergency Contact Details *

Primary emergency contact that you would like contacted in case of an emergency. Include their name, relation to you. This Information will also be kept with CFPA Staff and it will be CFPA staff responsibility to contact Emergency contact.

Emergency Contact Phone Number *

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms