MEDICAL FORM

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

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Date of Birth *

MM

DD

YYYY

Name *

Name of your emergency contact

First Name

Last Name

Mobile *

(###)

###

####

Secondary Phone

(###)

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COVID-19 Vaccination Status *

Have you Been Vaccinated for COVID-19. (check all that apply)

No

Yes - 2 Doses of Moderna

Yes - 2 Doses of Pfizer

Yes - 1 Dose of Johnson & Johnson

COVID-19 Booster *

Have you had at least one COVID-19 Booster

Yes

No

Do you have any of the following conditions?

Epilepsy/seizures

Bleeding/clotting disorder

Heart disease

Asthma/emphysema

High blood pressure

Diabetes

Sleep Apnea

OTHER

Today's Date *

MM

DD

YYYY