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Uhparticipantmedicalform2010

CRUISE: UNIVERSITY OF HAWAII
CONFIDENTIAL
MEDICAL RECORD AND PARTICIPANT INFORMATION
SEA EDUCATION ASSOCIATON
Instructions
: Participants must complete and return by April 15, 2010. You must notify SEA of
any medical concerns or issues that occur prior to sailing.


SSV
Corwith Cramer, Robert C. Seamans, are ocean going vessels which require the participation of all aboard in
order to operate. Many operations involve physical activity which in some cases may be demanding. The vessels
spend much of their time far from medical facilities and out of range of most means of medical evacuation. It is
essential that you inform us immediately of any condition which may affect your physical or mental abilities, or
which might require attention while you are on the vessel, for your own safety and that of your shipmates. In most
instances, given enough lead time, the ship's Medical Officer can usually contact your physician and ensure that
the ship is prepared for any special measures which your particular case might require.) However, SEA must reserve
the right at any time to decline participation to anyone with medical or physical problems which could create a
potentially dangerous situation at sea.
Name___________________________________ SS# or Passport# _______________________
Home Address _________________________________________________________Email: ___________________
Home Phone ______________ Cell _____________ Date of Birth _______ M/F _____ Ht. ____ Wt. _____
(info used for berth assignments)
Physician: _________________________Address: _________________________ Phone _____________
EMERGENCY NOTIFICATION
Name_____________________________________________ Relationship______________________
Address_______________________________________________________________Email :________________
Home Phone_________________ Other: ____________________
MEDICAL INSURANCE
You MUST be covered by a sickness and accident policy, which is valid in foreign countries. Please complete
the information below and sign confirming this policy will be in effect during your entire program.
Insurance Company______________________________ Policy Number________________________
Subscriber_____________________________________ Relationship to you____________________
Signature_____________________________________________________________________________

How would we reach this company if necessary? Phone Number: _______________________
SWIMMING ABILITY
For your safety, it is critical that the captain of the vessel be aware of your swimming/floating ability.
Can you swim? Y/N _______ Can you stay afloat, unassisted, for 30 minutes? Y/N ______
SEA SICKNESS
Meclizine and Promethazine are available on the ships to help with seasickness. Please check with your doctor
that you may take these medications if needed. Parent/guardian: I approve / I do NOT approve (circle one) offering the above medications to my daughter/son
for treating seasickness.______________________________ (for participant under 18.)

MEDICAL INFORMATION It is critical that you disclose all medical conditions/problems.
Problems with vision or hearing (glasses, contacts or hearing aid). Please check. Problems with teeth. Dizzy spells, fainting, convulsions, persistent headaches Frequent infection of throat, tonsils, sinuses, ears Chronic cough, bronchitis, bloody sputum Chest pains upon exertion or deep breathing Palpitation of the heart, murmurs, irregular beat, poor circulation Jaundice or hepatitis, frequent diarrhea or bloody stools Severe menstrual cramps, frequent abdominal cramps Chronic skin problems (rash, infection) Any severe injury to head, chest, or internal organs Urinary tract infections, painful or frequent urination, bed wetting Illness requiring hospitalization or prolonged incapacitation Frequent nausea or vomiting, food intolerances, indigestion/heartburn Cramps, heat exhaustion, or other reaction to high temperatures Claustrophobia, agoraphobia, acrophobia (strong fear of confined places, open areas, heights) Continuing use of alcohol, drugs, or medicines Diabetes, thyroid condition, bleeding problems, or epilepsy Episodes of depression, anxiety, hysteria or nervousness Venereal disease or sexually transmitted disease
ALLERGIES: Y/N ____DESCRIBE:Medications, Foods, Insect Bites? REACTION______________________
____________________________________________________________________________________________
If there is a history of severe allergic reactions, you must bring at least 2 Epipen Kits to sea.
REQUIRED IMMUNIZATION: TETANUS TOXOID series. Date of last booster (within 7 yrs.) _____________
PRESCRIPTION MEDICATION(S): Please Specify. Include dosage and purpose.
____________________________________________________________________________________________
____________________________________________________________________________________________
Have you received or are you currently receiving, psychiatric/psychological diagnosis or treatment? If so, please print
doctor’s name & address and include reason, dates, medications:
____________________________________________________________________________________________
____________________________________________________________________________________________
AUTHORIZATION
I certify that this health history, and all information on it, is complete and accurate, and that I am physically and emotionally fit to
participate in an extended offshore voyage. In the event I cannot make a decision in an emergency, I hereby authorize the Sea
Education Association, Inc. (SEA), its Doctor(s), ship’s Captain or Medical Officer to administer emergency medical treatment and
to hospitalize, secure proper treatment for, and to order injections, anesthesia, or surgery for me. I give permission for SEA staff to
share information from this form if needed for medical purposes. I understand that I am responsible for notifying SEA immediately
of any injury, illness or other medical condition or change to the medical information here provided. I certify that I am at least 18
years of age. (If not 18, parent/guardian must also sign.)
Date: ____________ Printed Name: _______________________________________________________________

PARTICIPANT SIGNATURE (required): _____________________________________________________
Parent/Guardian must cosign for participants less than 18 years of age _______________________________

PLEASE RETURN TO SEA EDUCTION ASSOCIATION
P.O. BOX 6,
WOODS HOLE, MA 02543

Source: http://www.geography.hawaii.edu/textFiles/UHPARTICIPANTMedicalForm2010.pdf

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