Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Email
*
Contact Number
*
Emergency Contact Name
First Name
Last Name
Emergency Contact Number
Can we release medical information to this person?
*
Yes
No
Can this person make medical decisions for you?
*
Yes
No
Family Doctor
First Name
Last Name
Name of Family Doctor's Practice/Clinic
If you have any medical conditions, please list them below.
If you're taking any medications, please list them below.
If any of your medications require refrigeration, please list them below.
If you have any allergies, please list them below.
Have you ever been hospitalized due to an allergic reaction?
Yes
No
Do you carry an Epi-Pen?
Yes
No
I acknowledge and agree that the Toronto People With AIDS Foundation (PWA) and the Friends For Life Bike Rally (FFLBR) may collect and retain information about me, such as my name, age, gender, and email address (“Personal Information”). Collection of this Personal Information and use of Personal Information is for the administration of the Software only. PWA and FFLBR will not sell, share, or transfer this data to third parties unless we indicate this to you. I understand that PWA and FFLBR may employ other companies to perform functions on our behalf, such as sending emails, or providing marketing assistance. These companies may have access to Personal Information needed to perform their functions, and may not use such information for other purposes. In the event PWA and FFLBR employ third parties, we will advise you of the name of those third parties. By assenting to this agreement, you agree that you understand and accept our data collection and privacy policy. I certify that the information provided on this form is accurate and complete to the best of my knowledge and contains no misrepresentations or material omissions. I will inform the Toronto People With AIDS Foundation’s Special Events Coordinator and Wellness Co-Leads of any relevant changes in my state of health subsequent to my application and prior to the Friends For Life Bike Rally. By entering my name in this form, I grant permission for this information to be provided to those with a legitimate need to know.
*
First Name
Last Name
Date of Signing
MM
DD
YYYY
I am a participant in the Friends For Life Bike Rally (the “event”). During the event I have requested massage and/or chiropractic services and/or complementary therapies from volunteers associated with the event providing such services, and I hereby consent to the services I have requested, pursuant to the Health Care Consent Act, 1996. In consideration of receiving the requested services, I acknowledge and agree to the following: 1. I will provide accurate and complete information about my health to the volunteer from whom I seek services. 2. I acknowledge and agree that any services provided will be based upon the personal health information provided by me. 3. I understand that I may withdraw my consent to services in writing at any time. 4. I understand that the volunteer may, in his or her discretion refuse me services. 5. I hereby, on my own behalf and on behalf of my heirs, estate, successors and assigns, release, waive and forever discharge the volunteer and the sponsor of the event, Toronto People With AIDS Foundation, its directors, officers, employees, agents and volunteers from whom I have sought services of and from all claims, demands, damages, costs, expenses, actions in law and in equity arising in any manner from the massage or chiropractic services provided to me, regardless of whether such loss or damage was caused or contributed to by negligence on the part of the volunteer. 6. I understand that there are inherent risks involved in receiving chiropractic services, massage services or complementary therapies including the possibility of bodily injury or death, and I voluntarily take such risks upon myself. 7. I confirm that I have read this consent and waiver. I understand its terms and effect, and I have agreed to it freely and voluntarily, without any inducement or coercion.
*
First Name
Last Name
Have you received massage therapy or chiropractic therapy before?
Do you have any internal pins, wires, artificial joints or special equipment?
What/where?
Are you currently receiving treatment from another health care professional for a musculoskeletal condition?
If yes, for what?
History of Head/Neck Conditions?
History of Respiratory Conditions?
History of Cardiovascular Conditions?
History of Other Conditions?
If you have any other medical conditions (digestive, haemophilia, osteoporosis, etc) please list them here
