Medical Clearance Form

Name *
First and Last name of a close friend or family member who we can reach out to if you need emotional support. Ideally list someone who would be sympathetic to this work. We will only reach out to your supporter if absolutely necessary.
Supporter Phone Number
Supporter Phone Number
Phone number at which we can reach the supporter you listed above.
Medical Information *
Do you have, or have you had in the past, any of the following medical conditions? Please select all that apply. Select "None of the Above" if applicable.