Name & date of the trip(s) you want to participate in. * Address * Apartment City * State/Province * Zip/Postal Code * Country * Home Phone Cell Phone * Email * Date of Birth * Country of Citizenship * Are you a current passport holder? * If Yes, Passport Expiration Date Do you presently use tobacco? * Do you presently use alcohol? * Have you ever used illegal or habit-forming drugs? * If Yes, date you last used illegal or habit-forming drugs: Do you have a criminal record? * If yes, please explain and include all charges and sentences.
The Buffalo Dream Center reserves the right to run a criminal background check on every perspective
Emergency Contact Address * Apartment City * State/Province * Zip/Postal Code * Emergency Contact Phone * Alternate Phone Emergency Contact Email * Relationship to Applicant * Do you have any physical disability? * If yes, please explain. Have you ever been treated for any mental or emotional condition? * If yes, please explain. Please list all existing medical conditions including allergies. If none, write none. * If you have allergies, are they life threatening? If yes, please explain. Please list all medication you are currently taking. If none, write none. * Will any problems result in hard physical labor? * Are you unusually sensitive to heat? * Have you ever been completely or partially overcome by heat? * If any of the above questions were answered yes, please explain: Name of Medical Doctor * Doctor Phone * Insurance Carrier * Insurance ID # * Name of insurance carrier *