Dragon Healer Demo graphic Information

• First Name
• Last Name
• Cell Phone #

  ###-###-####

• Mailing Address (Number, Street, City)
• E-mail Adress
• Date of Last Physical

  dd/mm/yyyy

• Approximate (clothed) weight in pounds (this is confidential, and is used only for balancing the boat)
• Preferred paddling side (new paddlers should leave this blank)
  Strong preference for the right side Strong preference for the left side Slight preference for the right side Slight preference for the left side No preference
• If you selected "strong preference", please list any relevant medical reasons for your selection

Emergency Contact Information:

• Name
• Relationship
• Phone Number

  ###-###-####

• E-mail

• Please list any other health concerns which may affect your participation in Dragon Healers. Be sure to include any prior health concerns (stroke, recurring injury, etc.) and allergies to any medication
• Have you ever been certified in First Aid? If so, when were you last certified? (month and year)
• Have you ever been certified in CPR? If so, when were you last certified? (month and year
• Do you have any other skills that you may be able to use in an emergency situation? Explain.

 

You must read and agree to the Healers Waiver before you are allowed to practice. (

Enter your full name in the box below if you have read the Healers Waiver