ACCTS West is a conference that is open to everyone.
This year it is being held at a Camp Grounds.
The grounds are beautiful but can be difficult to get
around if your disability is limiting.
Please be aware
.
Medical Information
Please fill out the form below to share important medical information with conference staff.
(All Information will remain Confidential)
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Your Name
Your Phone Number
Your E-mail Address
Emergency Contacts
Emergency Contact Name
Emergency Contact Address
City
State
Zip Code
Emergency Contact Phone Number
Emergency Contact E-mail
Physician's Name
Physician's Address
City
State
Zip Code
Physician's Phone Number
Physician's E-mail
Please list the following:
Allergies
Dietary Restrictions
Medical Conditions
Treated
Untreated
Describe
Current Prescription Medications*
* It is important to carry copies of prescriptions for all medications with you. If you want them in your file, please provide photocopies upon arrival.
Other Medications
Health insurance
Phone Number
It is important to carry a copy of your insurance card with you. If you want it in your file, please provide a photocopy of your insurance card upon arrival.
Are you medically disabled?
Yes
No
What are the legal conditions and/or limitations of your disability?
What activities would violate your disability status?
Other Medical Information
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