SBS HEALTH FORM

    Enrolment Details
    Full Name

    Date of Birth

    General Health Information
    Successful completion of SBS at YWAM Sheep River will typically involve tasks that require the following abilities; please comment on your ability to perform the following:

    Sit and study in a classroom environment (with short breaks) for several hours at a time

    [group no-sit]
    Please explain your difficulty with this task
    [/group]

    Stand at a workshop bench or kitchen counter etc, (with short breaks) for several hours at a time

    [group no-stand]
    Please explain your difficulty with this task
    [/group]

    Perform light tasks, e.g. cutting up vegetables, making beds, cleaning a bathroom, or carrying a small item (up to 15 lbs;7kg)

    [group no-carry]
    Please explain your difficulty with this task
    [/group]

    Use a computer and/or read documents (with short breaks) 8-10 hours in a day

    [group no-read]
    Please explain your difficulty with this task
    [/group]

    General household cleaning tasks, including the use of household cleaning chemicals

    [group no-chemical]
    Please explain your difficulty with this task
    [/group]

    Walk 3 miles (5km) in a day

    [group no-walk]
    Please explain your difficulty with this task
    [/group]

    Manage your time to meet frequent deadlines, there will be one or more assignments due each week

    [group no-assignment]
    Please explain your difficulty with this task
    [/group]

    Are you taking prescription medication? (for example, do you have an EpiPen?)

    [group taking-meds]
    Please explain your plan to ensure you have access to these medications during your time here (including outreach).
    [/group]

    Is there any general health information you believe we should be aware of?

    Vaccination Details
    You do not necessarily require all the following vaccinations, but this list will allow us to confirm which vaccinations you may wish to get before your course. Please do your best to find your vaccination records, but if you are uncertain for any of them, please select "No".
    Are you vaccinated against the following?

    Varicella (Chickenpox)
    Measles
    Tuberculosis
    Mumps
    Pneumococcal
    Meningococcal
    Diphtheria
    Tetanus
    Acellular Pertussis
    Polio
    Rubella
    Hepatitis A & B
    Hepatitis C
    Typhoid
    Japanese Encephalitis
    Dengue Fever
    COVID-19

    Emergency Contact
    Full Name of Emergency Contact

    Relationship to Contact

    Contact's Address

    Contact's Home Phone Number

    Contact's Cell Phone Number (optional)

    Contact's Email

    In case of emergency, I hereby agree to the performance of such treatment, including anesthesia and surgery, as the attending doctor or physician may deem necessary.
    I consent(required)

    Confirm & Submit
    Your data will be retained by YWAM Sheep River in accordance with their GDPR Privacy Notice
    I consent to this data storage(required)

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