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).
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Weight *
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Height *
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Insurance Coverage (Not required for participation in course.) |
Insurance Co
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Insurance Company Phone
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Physician Name
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Physician Telephone Number
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Insurance Policy ID Number
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Insurance Group Number
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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. |
Hepatitis B immunization is not a requirement for participation, but is highly recommended. |
Date of first Hepatitis B series
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Date of second Hepatitis B series
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Date of third Hepatitis B series
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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:
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If yes, please list them and describe what they are for.
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If yes, please explain.
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Medication for seizures, epilepsy
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Medication for heart disease or heart attack; other cardiovascular condition
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Medication for high blood pressure
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Diabetes or elevated blood sugar controlled by: |
Diet |
Pills |
Insulin |
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Medication for nervous or psychiatric disorders, e.g., severe depression
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If you answered yes to any of the above, indicate onset date, diagnosis, and any current limitations:
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Please add any additional information about your health history that you feel we should be aware of:
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