Coastal Ecosystems Research Foundation 2648 Tennis Cr., Vancouver, C.-B., Canada, V6T 2E1 (604) 224-2642 F/V Caitlin Bay, Duncanby Landing, Rivers Inlet, C.-B. V0N 1M0 (250) 949-1130

Medical Form

Please print this form, fill it out, and mail or fax it back to us at the Vancouver address above.

The information on this form will be used only to prepare the crew properly for any emergency 
situations and to signal any special requirements you might have - please don't be shy: it's a long 
way to the nearest pharmacy! This form will accompany you to medical care in an emergency. The 
information will otherwise be considered confidential once completed.

Name________________________________________Date of Birth_________________Phone # __________________
Address_____________________________________________________________________________________________
In case of emergency, contact :
Name________________________________________Relation_____________________Phone #____________________
Address_____________________________________________________________________________________________
Doctor___________________________________________________________________Phone #____________________
Medical Insur. Plan______________________Acct Number________________________________________________
Known Allergies (penicillin, hay fever, bee stings, shellfish, berries, etc.) 
____________________________________________________________________________________________________
Date of last Tetanus inoculation or booster :_______________________________________________________
                    current (within last 10 years) tetanus boosters are mandatory
Are you on any medications (prescription or nonprescription) ?   Yes__________  No__________________
If yes, please specify______________________________________________________________________________
Have you been under doctor's care in the last 12 months ?   Yes_________________ No_________________
If yes, please give 
details_____________________________________________________________________________________________
____________________________________________________________________________________________________

Chronic disability or illness (please list appropriate) :
(high blood pressure, heart condition, epilepsy, diabetes, susceptibility to colds, headaches, 
migraines, nosebleeds, fainting, asthma, emphysema, or others)
_______________________________________________________________________________________________
History of joint injury (tendonitis, bursitis, sprain, dislocation, or other) : Please describe and 
specify which joints.
_______________________________________________________________________________________________
Eyesight:       Excellent_______Good_________Fair_________Glasses__________Contact 
Lenses____________
(If you are dependent on glasses or contact lenses for adequate vision, we recommend you bring a 
spare set of glasses.)

Physical limitations________________________________________________________________________________

Psychological limitations (fear of 
water/heights/etc.)______________________________________________________

Other information_________________________________________________________________________________

If any of the above information changes, I will inform the crew in a timely manner such that changes 
can be recorded. 
I certify that the above is correct to the best of my knowledge and understand that the Coastal 
Ecosystems Research Foundation cannot be held responsible nor prepare for complications arising from 
information about my health and condition which I have neglected to include on this form.

__________________________________   __________________________________    _______________________
Name (please print)			Signature				Date