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THIS SECTION IS SECURE AND IS ONLY SEEN BY OUR MEDICAL DIRECTOR, FRANKLIN HUBBELL, DO.

STOP AND PLEASE READ - IF YOU ARE ATTENDING A SOLO COURSE THAT IS NOT AT OUR CONWAY, NH CAMPUS, THIS FORM IS NOT FOR YOU. PLEASE CONTACT THE COURSE SPONSOR DIRECTLY TO FILL OUT THEIR MEDICAL FORM SPECIFIC TO THEIR LOCATION. THANK YOU!

 

 

Please select who will be participating...
AdultMinor
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First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Medical Information - This section is secure and is only seen by our Medical Director, Franklin Hubbell, DO.

Please type in the course at our Conway, NH campus your are registered for below, including course type and dates (e.g. WFA, May 7-8, 2016).
Sex*
Female
Male

Weight *

Height *

Insurance Coverage (Not required for participation in course.)


Insurance Co

Insurance Company Phone

Physician Name

Physician Telephone Number

Insurance Policy ID Number

Insurance Group Number

Medical Information for WEMT & WEMT Part II Only:

If possible, please provide a record of all inoculations you have received within the past ten years to info@soloschools.com or fax to 603-447-2310.

A TB test IS REQUIRED within six months of your course start date to participate in the WEMT and WEMT Part II courses. Please email or fax a copy of the results from your doctors office to info@soloschools.com or 603-447-2310 


Date of TB Test (required for WEMT and WEMT Part II courses)

Hepatitis B immunization is not a requirement for participation, but is highly recommended.


Date of first Hepatitis B series

Date of second Hepatitis B series

Date of third Hepatitis B series

General Health Information for all courses

For safety reasons, we need to be aware of any special health concerns you may have.   This information is confidential and will be reviewed by a physician who may contact you for additional information.


List any sensory, physical, learning, or emotional limitations and state how they affect you and the medications, physical aids, or strategies that your condition requires:
Are you currently taking any over-the-counter or prescription medications?*
No
Yes

If yes, please list them and describe what they are for.
Are you currently under the care of a medical specialist?*
No
Yes

If yes, please explain.
Have you had a tetanus shot in the last 4 years?*
No
Yes
Have you received all childhood disease immunizations?*
No
Yes
Have you been immunized against Hepatitis B? (Not required.)*
No
Yes
Any illness or injury in the last 5 years?*
No
Yes
Head/Brain injuries, disorders or illnesses?*
No
Yes
Seizures, epilepsy?*
No
Yes

Medication for seizures, epilepsy
Eye disorders or impaired vision (except corrective lenses)?*
No
Yes
Ear disorders, loss of hearing or balance?*
No
Yes
Heart disease or heart attack; other cardiovascular condition?*
No
Yes

Medication for heart disease or heart attack; other cardiovascular condition
Heart Surgery (valve replacement/bypass, angioplasty, pacemaker)?*
No
Yes
High blood pressure?*
No
Yes

Medication for high blood pressure
Muscular disease?*
No
Yes
Shortness of breath?*
No
Yes
Lung disease, emphysema, asthma, chronic bronchitis?*
No
Yes
Kidney disease, dialysis?*
No
Yes
Liver disease?*
No
Yes
Digestive problems?*
No
Yes
Diabetes or elevated blood sugar?*
No
Yes
Diabetes or elevated blood sugar controlled by:
Diet
Pills
Insulin
Nervous or psychiatric disorders, e.g., severe depression?*
No
Yes

Medication for nervous or psychiatric disorders, e.g., severe depression
Loss of, or altered consciousness?*
No
Yes
Fainting, dizziness?*
No
Yes
Sleep disorders, pauses in breathing while asleep, daytime sleepiness?*
No
Yes
Stroke or paralysis?*
No
Yes
Missing or impaired hand, arm, foot, leg, finger, toe?*
No
Yes
Spinal injury or disease?*
No
Yes
Chronic low back pain?*
No
Yes
Regular, frequent alcohol use?*
No
Yes
Narcotic or habit forming drug use?*
No
Yes

If you answered yes to any of the above, indicate onset date, diagnosis, and any current limitations:

Please add any additional information about your health history that you feel we should be aware of:
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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