Confidential Medical Record 

RMRP programs include challenging experiences that may involve strong emotional and physical release. This training may not be appropriate for applicants with major medical or emotional problems. In order to acquaint our staff with the applicant’s medical needs, we require that you complete this Confidential Medical Record. If there is any doubt about whether the applicant should participate, discuss your concerns with us or with the applicant's physician or therapist. We will keep this information strictly confidential, except that we reserve the right to share it with emergency medical personnel as needed.

For everyone’s safety, and in order to acquaint our staff with the young man’s medical needs, we ask parents or guardians to complete this Confidential Medical Questionnaire. If the young man becomes ill or is injured on the weekend, after trying to contact you, we may need to share this information with medical personnel. Otherwise, all information will be kept strictly confidential. Please complete every item in every section. Mark N/A if any section is not applicable or if you don’t want to share the information.