CRUISE: UNIVERSITY OF HAWAII CONFIDENTIAL MEDICAL RECORD AND PARTICIPANT INFORMATION SEA EDUCATION ASSOCIATON Instructions: Participantsmust complete and return by April 15, 2010. You must notify SEA of any medical concerns or issues that occur prior to sailing. SSVCorwith 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 INFORMATIONIt 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
FOR IMMEDIATE RELEASE THIS RELEASE IS PROVIDED FOR YOUR USE EITHER IN PART OR IN ITS ENTIRETY. WRITER CREDITS SHOULD REFLECT “URBANSCAPES” ACCORDINGLY. Creativity’s Big Weekend. Join Franz Ferdinand, Tegan & Sara, Two Door Cinema Club and dozens more for Urbanscapes Festival 2013, The Big Weekend of creative arts, music and community, at MAEPS on Saturday November 23rd and Sun
MATERIAL SAFETY DATA SHEET COMPUDOSE 100, 200 AND 400 Revision No: 4.0, 20 March 2012 STATEMENT OF HAZARDOUS NATURE: The intact Compudose implant is not considered hazardous under normal handling procedures. The following Statement of Hazardous Nature refers to the contents of the implant which contain oestradiol: Hazardous according to the criteria of Worksafe Australia: Toxi