SayPro Health and Safety Form: A form to collect any health-related information (such as allergies, medical conditions

SayPro Health and Safety Form

Purpose:
The SayPro Health and Safety Form is designed to collect essential health-related information from all participants in order to ensure a safe and supportive environment throughout the retreat. This form helps us accommodate specific medical needs, prevent potential health risks, and respond effectively in case of any emergencies. Your privacy and confidentiality are our priority, and all information provided will be kept strictly confidential and used solely for the purposes of participant safety.

Instructions:
Please complete the following form with accurate and honest information. If you have any concerns or questions regarding the form, please feel free to reach out to the retreat organizers.

Participant Information:
1. Full Name:
– (First Name, Last Name)

2. Date of Birth:
– (DD/MM/YYYY)

3. Emergency Contact Information:
– Name:
– Relationship:
– Phone Number:
– Email (if available):

Health Information:
4. Do you have any allergies?
– (Please list all known allergies, including food, medication, insect stings, etc.)
– If yes, please describe the allergy and any reactions you may have:

5. Do you have any pre-existing medical conditions?
– (Please provide details on any chronic conditions such as asthma, diabetes, epilepsy, heart conditions, etc.)
– If yes, please provide more information on the condition and any special care requirements:

6. Are you currently taking any medications?
– (Please list all medications you are taking, including prescribed, over-the-counter, or herbal supplements.)
– If yes, please provide the medication name, dosage, and frequency:

7. Do you require assistance with mobility, such as walking aids, or need special accommodations for any physical limitations?
– (Please specify any mobility needs or restrictions.)

8. Do you have a history of mental health conditions?
– (Please describe any mental health concerns, such as anxiety, depression, or other relevant conditions.)
– If yes, please provide details on the condition and how it may impact your participation:

9. Have you had any recent surgeries or hospitalizations?
– (Please provide details on any recent surgeries, treatments, or hospital stays within the last year.)

Dietary Information:
10. Do you have any specific dietary needs or restrictions?
– (This includes vegetarian, vegan, gluten-free, kosher, halal, or any other special dietary requirements.)
– If yes, please describe:

11. Do you have any food allergies or intolerances?
– (Please list food allergies such as nuts, dairy, gluten, or any specific foods that should be avoided.)

Emergency Preparedness:
12. In the event of an emergency, do you have any specific medical instructions that the staff should be aware of?
– (For example, if you require an epinephrine injector for severe allergies, or if you need specific instructions for medication administration.)

13. Do you have a first aid kit or medical supplies you need to bring to the retreat?
– (Please list any personal medical supplies, such as insulin, inhalers, or other items.)

14. Any additional information that may be important for us to know?
– (This could include anything not covered in the previous sections, such as sensitivities to weather, environmental factors, or other health considerations.)

Participant’s Consent:
– By submitting this form, I confirm that the information provided is accurate and complete to the best of my knowledge. I understand that the retreat organizers may need to use this information to ensure my safety and well-being during the retreat, and that all health-related information will be kept confidential.
– I also understand that if my health or medical condition changes before or during the retreat, I will inform the organizers immediately.

Signature of Participant:
– (Signature, Date)

Organizer’s Use Only:
– Received by (Organizer’s Name):
– Date Received:
– Special Notes / Accommodations Provided:

This form should be submitted at least two weeks before the retreat to ensure that we can accommodate all health and safety needs. Thank you for providing this essential information to help make the retreat a safe and enjoyable experience for everyone.