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—Please choose an option—Not a problemThis could be difficult
[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—Please choose an option—Not a problemThis could be difficult
[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)—Please choose an option—Not a problemThis could be difficult
[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—Please choose an option—Not a problemThis could be difficult
[group no-read] Please explain your difficulty with this task [/group]
General household cleaning tasks, including the use of household cleaning chemicals—Please choose an option—Not a problemThis could be difficult
[group no-chemical] Please explain your difficulty with this task [/group]
Walk 3 miles (5km) in a day—Please choose an option—Not a problemThis could be difficult
[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—Please choose an option—Not a problemThis could be difficult
[group no-assignment] Please explain your difficulty with this task [/group]
Are you taking prescription medication? (for example, do you have an EpiPen?)—Please choose an option—YesNo
[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)—Please choose an option—YesNo Measles—Please choose an option—YesNo Tuberculosis—Please choose an option—YesNo Mumps—Please choose an option—YesNo Pneumococcal—Please choose an option—YesNo Meningococcal—Please choose an option—YesNo Diphtheria—Please choose an option—YesNo Tetanus—Please choose an option—YesNo Acellular Pertussis—Please choose an option—YesNo Polio—Please choose an option—YesNo Rubella—Please choose an option—YesNo Hepatitis A & B—Please choose an option—YesNo Hepatitis C—Please choose an option—YesNo Typhoid—Please choose an option—YesNo Japanese Encephalitis—Please choose an option—YesNo Dengue Fever—Please choose an option—YesNo COVID-19—Please choose an option—YesNo
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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