• Emergency contact information

    In case of emergency please contact:
  • If unable to reach the above person please contact:
  • Health info

    We hope you stay healthy during your stay with us, but we need some basic health information:
  • Shirt Size

  • Technology

    Participants 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.
  • Waiver of Liability

  • I 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.
  • Using your mouse, please sign your name if you agree to the terms of the above waiver of liability.

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