Participant Health History
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employer/School
Parent/Legal Guardian Name if a minor
Parent/Legal Guardian Phone Number if a minor
How did you hear about the program?
Health History
Describe your current health status, particularly regarding the physical/emotional demands of working with animals and around at risk individuals. Please list any physical challenges that might make working around animals or people difficult for you. Please include any relevant medical conditions.
*
Allergies
Do you carry an epipen
*
Yes
No
Do you carry an inhaler?
*
Yes
No
Current Medications prescription and over-the-counter (name, dose and frequency)
Date of last Tetnus Shot
*
Tuberculosis Test+- Date:
*
Signature of Participant or Legal Guardian
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: