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Wilderness Medicine Student Health + Information Form
This form helps our team support your learning and wellbeing during this course. We ask you to complete it honestly and thoroughly. All responses will be kept confidential and are only shared with your direct instructors on a need-to-know basis to ensure appropriate support. All information will be handled with privacy and confidentiality.
Course Type
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WFA, WAFA, WFR-R, WFR, WEMT, WPRO
Start Date of Course
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-
Month
-
Day
Year
Date
Full Legal Name of Participant
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Preferred Name
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What pronouns do you use?
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Date of Birth
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Age
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Email
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example@example.com
Phone Number
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-
Area Code
Phone Number
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
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List full name, relationship and telephone (indicate type - work, cell, etc.)
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Learning Information
We are committed to creating a welcoming, affirming and supportive learning environment. Please share anything you feel comfortable with to help us better understand your learning style and how we can best support your experience in this course.
Have you taken a wilderness medicine certification course in the past?
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Yes
No
How comfortable do you feel recreating in a remote, backcountry setting away from emergency services?
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Very uncomfortable
1
2
3
4
Very comfortable
5
1 is Very uncomfortable, 5 is Very comfortable
How prepared are you to effectively respond in a remote, emergency situation?
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Very unprepared
1
2
3
4
Very prepared
5
1 is Very unprepared , 5 is Very prepared
How much training do you have in mentally preparing to respond in an emergency situation?
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No training
1
2
3
4
Extensive training
5
1 is No training, 5 is Extensive training
Have you ever been involved in a backcountry rescue?
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Yes
No
Have you ever been in a medical situation (front or backcountry) where you felt uncomfortable receiving or providing care?
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Yes
No
How important is it to you currently that your adventure companions have wilderness medicine training?
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Very unimportant
1
2
3
4
Very important
5
1 is Very unimportant, 5 is Very important
In wilderness medicine courses, we talk and practice through topics that may be challenging to envision and learn about such as life threatening conditions and death. Are there any specific topics from your past that you are nervous about covering or would like to speak with an instructor beforehand about?
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Indicate if you would you like a private check-in before class.
We want our classrooms to be a place where students feel safe, respected, supported in growing and making mistakes while learning. Is there any particular action that can help facilitate that environment for you?
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Do you identify with having any learning challenges or accessibility needs you'd like us to be aware of? Please describe anything that may be helpful for your instructors to know.
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Include supports, adaptations or practices help you learn best.
Include any information you would want you instructor to know that wasn’t addressed in this form.
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Medical History
Describe only in as much detail as you feel is relevant to your ability to complete the course. We ask this to be best prepared to support you, not to exclude you. We trust your knowledge of your own body and needs.
List any pertinent medical, injury or surgical history
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List any side effects from medications you would like us to be aware of.
List any food/dietary restrictions and allergies with associated reactions
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Do you carry a personal supply of epinephrine?
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Yes
No
Does Not Apply
Describe any mental health conditions you would like us to be aware of
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Include any special medical or personal information you would want an instructor or emergency care provider to know or relevant information that wasn’t addressed in this form
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Group Agreements & Community Norms
To help create a supportive learning environment, we ask that everyone review the following group norms. These principles guide how we learn, practice skills and care for one another throughout the course.
Wilderness Medicine Course Community Agreements
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I will ask for consent before touching anyone or practicing any skills on another person.
I understand that everyone carries different life experiences and I will respect personal boundaries and individual comfort levels.
I will give feedback kindly and clearly and I will ask before offering it to someone else.
I will receive feedback as an opportunity to learn, not as a judgment or failure.
I will use inclusive and affirming language and avoid making assumptions about someone’s background, body or identity.
I will keep personal stories shared in this space confidential, unless I have permission to share them elsewhere.
I will take care of my own needs, hydrating, taking breaks, asking for help and support others in doing the same.
I will do my best to stay present and engaged, knowing that we all have different capacities on different days.
I will acknowledge that we are learning on Indigenous land and act with respect toward the people and places connected to it.
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Consent + Participation Acknowledgement
By signing below, I affirm that the information I have provided is accurate and complete to the best of my knowledge. I acknowledge that this course may involve physical and emotional challenges. I agree to uphold group and community norms and to participate in a manner consistent with my personal capacity and the expectations of the course.
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Yes
Signature
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If I am taking this course as a WFR-Recertification, upload past WFR card here!
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