Medical Information

Please fill out this form before our retreat. We are going to have a wonderful time!

Medical Form

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Emergency Contact

First Name

Last Name

Emergency Contact Phone

(###)

###

####

MEDICAL INFORMATION

Allergies

Do you have any allergies to medications, food, or other substances? If yes, please list them.

Medical Conditions

Do you have any medical conditions that require special attention or modification of activities (e.g., diabetes, asthma, heart conditions, physical limitations)? If yes, please describe:

Dietary Restrictions

Do you have any dietary restrictions (e.g. vegetarian, vegan, gluten-free, allergies)? If yes, please list them:

MENTAL HEALTH

Any current mental health concerns?

Are there any current mental health concerns that Vivum organizers should be aware of (e.g., anxiety, depression)?

In the last month, have you felt like your life was not worth living?

If so, please explain:

Attempted to take your life within the last 6 months?

Have you made an attempt on your life within the last 6 months? If so, please explain:

Waiver Signature

By checking the box "YES" below you are agreeing that: 1. I understand that participation in Vivum may include physical activities such as walking, sitting for extended periods, and light stretching. I confirm that I am physically and mentally able to participate in these activities. If I have any concerns, I will consult with my physician prior to the retreat. 2. I understand that the Vivum organizers are not medical professionals and cannot provide medical advice or treatment. In case of a medical emergency, I authorize the Vivum organizers to contact emergency services on my behalf.

Four people, arms around each other, standing on a grassy hill at sunset.

Medical Information

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