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FGPC Health Reporting Form
Please complete this form whenever an illness presents itself.
Please note, for persons under the age of 19, Parent or Guardian must complete this form.
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* Indicates required question
Person with the illness or exposed to this illness (if contagious)
First Name
*
Your answer
Last Name
*
Your answer
Email Address
*
Your answer
Emergency Contact Name
*
Your answer
Emergency Contact Email Address
*
Your answer
Emergency Contact Phone
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Status at FGPC
Choose all that apply.
FGPC/WF Employee
FGPC Cohort Paddler
FGPC EAP paddler (OC1, Kayak, EAP)
WF EAP Gym
If you selected FGPC Cohort Paddler above, please indicate the name of your cohort and your cohort captain.
Your answer
Are you (or is the person who has the illness) under the age of 19?
Yes
No
Clear selection
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This form was created inside of Fairway Gorge Paddling Club Society.
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