Registration form for Participation
in Summer Study Programs
GENERAL MEDICAL
For ARTIS to maintain our high standards of safety and ability to respond
to emergencies this form needs to be filled out and submitted
along with the Registration and Waver forms.
Our Florence program is not recommended for persons over 70 years of age.
Note: Any participants that are 70 years or older or anyone who has been
hospitalized within the last 2 years must have the bottom half of this form
signed by their doctor. This is for your own comfort and safety.
SELF EVALUATION
Since your period of overseas stay is longer with the ARTIS Programs, all
participants should be in good mental and physical condition and prepared to
enjoy considerable walking. ARTIS programs offer a wide range of
environments to explore in each country, consequently many villages are
paved with uneven cobblestones, country walks are on footpaths or
unpaved roads, palaces and art museums were built in the age of the grand
staircase and ground floor apartments are hard to come by.
Since each program is different, we can generally request that participants
be capable of walking 1-2 miles at a time.
Although participation in the daily tour activities is purely optional and
certain sites can be skipped, it is best to contact ARTIS before registering
for more detailed information about each location, should you be concerned
if the program is for you.
The ARTIS programs are not recommended for people with failing memory, who become disoriented or lost easily, walk slowly or require frequent rests. Any participants who require special assistance must be accompanied by a helper who is also capable of and totally responsible for providing such assistance.
MEDICAL HISTORY
A) Have you had any surgery or been hospitalized in the last two years? If
so, explain.
B) Are you currently under medication?
Yes No (circle one)
What kind? What substitute can you use?___________________________
C) Do you have any long term illnesses such as diabetes, depression etc. that require daily injections or medication?
Yes No (circle one)
Explain:________________________________________________________
D) Have you been diagnosed with any heart problem?
Yes No (circle one)
Explain:________________________________________________________
E) Additional information ARTIS should know concerning your health:
______________________________________________________________
MEDICAL STATEMENT
1) To the best of my understanding I am in good health and have no need
for special assistance during the ARTIS tour.
2) I certify that I have enough prescribed medication to last for the duration
of the program,
3) I am capable of walking two miles a day and climbing stairs.
Signature ________________________ Date: ___________________________
DOCTOR STATEMENT
Note: Any participants that are 70 years or older or anyone who has been
hospitalized within the last 2 years must have the bottom half of this form
signed by their doctor. This is for your own comfort and safety.
I ____________________________ MD, certify that to the best of my knowledge
__________________________ is in good physical and mental health and does
not require special assistance. That sufficient medication has been
prescribed to last for the duration of the trip and that walking two miles a
day or climbing stairs should not be a problem.
