Health PASS participant name* First Last Health PASS participant email* Emergency contact informationIn case of emergency please contact:Name* First Last Relationship*Primary phone*Secondary phoneIf unable to reach the above person please contact:Name First Last RelationshipPrimary phoneSecondary phoneHealth infoWe hope you stay healthy during your stay with us, but we need some basic health information:Please list your health insurance carrier:Do you have any health conditions we should be aware of?Shirt SizeT-shirt size Small Medium Large XL XXL XXXL TechnologyParticipants use laptops throughout the duration of the Health PASS programs. Please let us know if you plan to bring your own laptop or would like DMU to provide you with a laptop for use during the program.Laptop preference* I will bring my own laptop I would like to use a DMU laptop Waiver of LiabilityI hereby acknowledge that I am voluntarily participating in Des Moines University’s Health P.A.S.S. program. I am aware that participating in Health P.A.S.S. involves potential risks and hazards involving personal safety on and off-campus including housing and transportation, financial loss, cost of medical care, and the like. I further understand that I have the responsibility to cover any and all health care services which might result from attending Health P.A.S.S. I voluntarily agree to personally assume all such risks and responsibilities. I release the University, its directors, employees and agents from any and all responsibility or liability for injury, financial loss and/or other liability of any and every type which may arise out of my participation in Des Moines University’s Health P.A.S.S. Program. Signature*Using your mouse, please sign your name if you agree to the terms of the above waiver of liability. Δ
