The health and well-being of all who attend an event sponsored by Illuman of Illinois is always a priority. Due to the ever-changing nature of the COVID-19 virus, safety measures will be determined and shared closer to the start of the Men’s Rites of Passage. We will follow all safety protocols in accordance with Center for Disease Control and State and Local guidelines specific to the location of the event. We will require attendees to follow all stated precautions.

(PLEASE ANSWER ALL QUESTIONS BELOW)

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email *

Phone *

Country

(###)

###

####

Best Time to Call *

Date of Birth *

YYYY

Emergency Contact Information

First Emergency Contact *

First Name

Last Name

Relationship to Contact *

First Contact Phone *

(###)

###

####

Second Emergency Contact *

First Name

Last Name

Relationship to Contact *

Second Contact Phone *

(###)

###

####

Confidential Medical Questions

We respect your privacy. All of the information you provide is kept confidential. Please answer these questions thoroughly and to the best of your knowledge.

Height *

e.g. 5' 10"

Weight *

# in pounds e.g. 195lbs

Do you have specific food or nutritional requirements? * *

Vegetarian

Glutton Free

Lactose Intolerant

Other

None

Apart from "none," if you checked any of the above, please comment:

Do You have any of the following conditions? *

Epilepsy/seizures

Bleeding/clotting disorder

Heart attack

Heart disease

Heart murmur

Stroke

Asthma

Emphysema

High blood pressure

Diabetes

Hypoglycemia

Lung disease

Seizures of any kind

Others we should know about

None

Apart from "none," if you checked any of the above, please comment:

Allergic reactions *

Do you have any oft he following?

Environmental substances

Foods

Drugs

Sensitivity to insects

Sensitivity to stings

Anaphylatic shock

None

Apart from "none," if you checked any of the above, please comment:

Do you carry an EpiPen? *

Do you have any of the following disabilities? *

Back

Hip

Ankles

Other

None

Apart from "none," if you checked any of the above, please comment:

When walking *

If you walked on the level for a mile at an average pace, would you:

Get out of breath.

Have chest pain.

Have leg pain.

Develop muscle fatigue.

OTHER

None

Apart from "none," if you checked any of the above, please comment:

Medications *

If yes, for each please list condition, medication and dosage, e.g. High blood pressure, Lisinipril, 40mg. daily

Physical fitness *

Treatment *

Are you currently (or within the past 2 years) receiving treatment form a physician or other health care professional for any physical or psychological reason?

If you answered YES above, please describe:

Last Tetanus Shot *

YYYY

Have you been FULLY vaccinated and boosted for COVID19? *

Have you ever been told that your SNORING is serious enough that it can disturb others? *

Do you use a CPAP machine? *

Will you require assistance with any specific medical condition while you at at the MROP? *

If you answered YES above, please describe:

Additional comments

Is there anything else you feel we should know about you (your history or any other physical or emotional conditions) to help us support you during your time with us? Please specify:

Form Authorization

I authorize the Illuman of Illinois staff to furnish the information that I have completed above to medical professionals providing me emergency care during this event. *

Yes, I authorize Illuman of Illinois to release this medical information in the event of an emergency.

No, I do not authorize IIluman of Illinois to release this medical information in the event of an emergency.

Signature

Signature *

By typing your full name in this field you are confirming all the above information is correct.

Today's Date *

YYYY

Upon arrival at the MROP, you will be provided with a printed copy of this form for your signature. We respect your privacy. All of the information you've provided is kept confidential.

In-Person Signature

In-Person Date

Thank you very much for completing the Confidential Medical Questionnaire. This is essential for ensuring the health and safety of every man participating in the upcoming MROP at Pilgrim Park Your responses will be kept confidential and a representative will be contacting you regarding any special needs or requests.

CONFIDENTIAL MEDICAL QUESTIONNAIRE

This form is for men who have already received an acceptance notice for the MROP program, or if you are registering for the Initiator or the RIM programs. Please complete and submit this confidential medical questionnaire.

2024 MROP PILGRIM PARK
CONFIDENTIAL MEDICAL QUESTIONNAIRE

A community of men transforming other men through a loving power greater than ourselves.

Privacy Policy•terms of service•Nondiscrimination Policy•cookies Policy

e-mail: convener@illumanillinois.org

© 2025 ILLUMAN OF ILLINOIS

CONFIDENTIAL MEDICAL QUESTIONNAIRE

This form is for men who have already received an acceptance notice for the MROP program, or if you are registering for the Initiator or the RIM programs. Please complete and submit this confidential medical questionnaire.

2024 MROP PILGRIM PARKCONFIDENTIAL MEDICAL QUESTIONNAIRE

A community of men transforming other men through a loving power greater than ourselves.

Privacy Policy•terms of service•Nondiscrimination Policy•cookies Policy

e-mail: convener@illumanillinois.org

© 2025 ILLUMAN OF ILLINOIS

2024 MROP PILGRIM PARK
CONFIDENTIAL MEDICAL QUESTIONNAIRE