General Health Information

Betty J. Borry Breast Cancer Adventure Weekend, Inc. dba Betty J. Borry Breast Cancer Retreats

This information will be used on a need to know basis only and will be stored according to our privacy protection policy.

First Name

Last Name

Subject

Retreat: name and date

Date of Birth

Address

City/Town

State/Province

ZIP/Postal Code

Phone

Emergency Contact Information

Contact Name

Contact phone

Are you taking medications now?

Yes

If so, please list meds

Do you have any allergies?

Yes

Drug Allergies

Other Allergies (food, pollen, insect bites?)

Do you have any physical handicaps, recent surgery or any other restrictions which may limit your program participation

Yes

If so, what?

Covid - 19 Vaccination Record

1st Dose - Vaccine name and date:

2nd Dose - Vaccine name and date:

Booster Dose - Vaccine Name and date

Comments

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