Application Part 2 (pdf) - NOLS

I N S U R A N C E F O R MNOLS requires that all students have their own health insurance. Please complete this form sothat we will have information concerning your insurance coverage. It is your responsibility tomake sure your insurance will cover you for the duration of the course. The student will beresponsible for obtaining any necessary pre-admission review.________________________ ___________ _______________________________________Student Name CMWE 07/20/2013____________________________________Birth Date (dd/mm/yyyy)_______________________________________Application ID # (Office Use Only)No One Will Go On A Course Without Health Insurance Coverage. If you do not alreadybelong to a regular health program, we suggest a short-term policy, which you may buy fromyour local insurance agent. Non- U.S. citizens, please indicate your primary health coverage andany out-of-country travel insurance.Name and Address of Person Under Whose Name the Policy is Carried____________________________________Name_____________________________________Street Address_______________________________________( )________________________________City, State/Province Zip/Postal Phone Date of BirthInsurance Company Information_______________________________________________________________________________NamePolicy Number_______________________________________________________________________________Group NumberAgreement NumberAddress Where Claims Must Be Submitted_______________________________________________________________________________NameStreet Address________________________________________(______)________________________________City, State/Province Zip/Postal PhoneIf Group Insurance, Give Name of Group (employer, union or association through which thestudent is insured)_______________________________________________________________________________NameNOLS Professional Training 284 Lincoln Street, Lander, WY 82520 Insurance (800) 710-­‐6657 ext. 3 Page 1 of 1

Allergies25. Is he/she allergic to any foods? YES NODescribe:_________________________________________________________________________26. Are there any dietary restrictions? Please specify. YES NO vegetarian vegan other27. Has he/she had any systemic allergic reactions to insects, bee/wasp stings, or medicationsinvolving hives, swelling of face/lips or difficulty breathing? YES NOIf appropriate please bring a personal supply of epinephrine, preferably in a pre-loadedautoinjector, and know how to use it.Examiner’s specific comments: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________28. Any other allergies? YES NOExaminers Specific Comments: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________29. Water may be disinfected with iodine. Is iodine contraindicated? YES NOMedications30. Is he/she allergic to any medications? YES NOIf yes, please list: __________________________________________________________________________________________________________________________________________________________31. Does this person plan to take any prescription or non-prescription medications on thecourse? YES NONOLS courses travel in remote areas where access to medical care may be one or moredays away. The student must understand the use of any prescription medications theymay be taking. Written specific instructions are necessary. All Students who are requiredby their personal physician, psychiatrist or health care provider to take prescriptionmedications on a regular basis must be able to do so on their own and without additionalsupervision.Medication Dosage Side Effects/Restrictions Prescribed by? For What Conditions?_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________If Medication or Condition Changes Prior to Course Start, Please Inform NOLS.Cold, Heat, Altitude32. History of frostbite or Raynaud’s Syndrome? YES NO33. History of acute mountain sickness, high altitude pulmonary/cerebral edema? YES NOWhen did the illness occur? _____________________________________________________________________________________________________________________________________________34. History of heat stroke or other heat related illness? YES NOExaminer’s specific comments: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________Medical 2012© 2012 National Outdoor Leadership School5

Fitness (please provide details concerning the students exercise regime)35. Does the applicant exercise regularly? YES NOActivity ___________________________ Frequency______________________________________Duration/Distance _________________ Intensity Level Easy Moderate CompetitiveActivity ___________________________ Frequency______________________________________Duration/Distance _________________ Intensity Level Easy Moderate Competitive36. Does this person smoke? If so how much? YES NOThere is no smoking allowed on NOLS courses. We recommend that applicant quit now.37. Is this person overweight? Underweight? If so, how much? __________ YES NO38. Swimming ability (CHECK ONE): Non-swimmer Recreational CompetitivePhysical ExaminationA physician, F.N.P. or P.A. must read and fill out pages 1-6. Physical examination data cannotbe more than a year old from the starting date of the NOLS course. (Please type or printlegibly)NOLS Requires a Tetanus Immunization Within 10 Years of the Start Date of the Course.Expeditions Outside the U.S. May Require Additional Immunizations. Please refer to yourcourse description for specific information.______________ ____________ ______ /_______ /______ __________ ___________Blood Pressure Pulse Last Tetanus Inoculation Height WeightGeneral Appearance, Impressions and Comments:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Examiner’s Name(______)___________________________Phone______________________________________________________ ____________ ________________Street Address State Zip_______________________________________________________ _______ /_________ /_________Physician, F.N.P. or P.A. SignatureDate:By my signature, I attest that the person named on page one of this form is medicallycleared to participate on a NOLS course based on the expedition informationprovided on page 1 of this form along with the background information provided bythe applicant and my physical examination of him/her.Please Return All Six Pages To: NOLS, 284 Lincoln St. Lander, WY 82520Medical 2012© 2012 National Outdoor Leadership School6