Lamanai Archaeological Project Medical Form

Lamanai Archaeological Project Medical Form
2008

Before you register we need information on your general health profile and any medical needs. Ask your family doctor to send us a letter attesting to your reasonable fitness to attend a field school under humid tropical conditions. It is important for us to have this information on hand in case of an emergency. This information will be kept strictly confidential.

Name:
Home & Mobile Telephone:
E-Mail address::
Address:
City:
State, province or country:
Zip or Postal Code:
Country:
Date of Birth
Gender:
In case of an emergency, please contact:
Name(s):
Relationship:
Address:
Telephone:
Family Physician:
Telephone:
Mailing Address:
Any allergies or existing medical conditions:

Any medications you take:

Please fill out this form, print it and send by mail to:

Dr. Scott E. Simmons

Department of Anthropology

University of North Carolina Wilmington

601 South College Road

Campus Box 5907

Wilmington, North Carolina 28403-5907
USA