The person presenting this document has asked to
participate in a program of biblical studies and excursions
in the Holy Land.
Weekly day and/or overnight excursions require some
strenuous walking and occasional climbing.
The
Patient
Name
Age
Height
Weight
General
Health
Significant
impairment or disability (e.g. sight, hearing
etc.)
Conditions
requiring prescription medication or special dietary
practices (e.g. diabetes, epilepsy, hypertension,
etc.)
Conditions
requiring periodic supervision of a physician
while here at the Centre.
allergic
to drugs/medication? Specify
Blood
Pressure
Present
drug medication used
Special:
Heart - Hiking and Climbing
If
there is any heart or other history suggesting
limits for physical exercise, please indicate
Present
drug medication used
Is
the person presently under any supervision or
medication for heart problem?
Has
the person received treatment for alcoholism?
Check
as appropriate
I have given the student a
thorough medical and in my clinical judgment this
person is fit to participate in strenuous walking
and occasional climbing.
Although I endorse, this student's participation in the program,
certain limitation(s) should be placed on this
person's physical activities.(work, hikes, athletics, etc.)
I do not feel the student's
health would permit her/him to attend your program.
The
Patient 