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PHYSICAL AND PSYCHOLOGICAL HISTORY

Please complete the following questions about your physical and psychological well-being.

* Indicates required field

Name *

First

Last

Email *

Module 2 in Bhutan involves walking pilgrimages in remote, rural and high altitude environments where medical facilities are basic. If you have any mobility or special needs then it may be possible to arrange alternative activities . Please provide information about any mobility or special needs. *

Do you have any history of physical illness or any disabilities, which may affect your participation in the Right Livelihood Programme? *

Have you ever been diagnosed with or experienced any mental health issues e.g. depression, eating disorders, anxiety, drug/alcohol abuse? If yes, please give details of condition(s) and date(s). *

Are you taking any medication for any physical or psychological condition? If yes, please give details of condition and medication. *

EMERGENCY CONTACT DETAILS

Name of someone we can contact in case of emergency: *

Emergency Contact Phone Number *

I agree to take full responsibility for myself during the Right Livelihood Programme. I understand that all participants need to observe the terms and conditions, take out appropriate health and travel insurance, and that the programme is undertaken and continued with the agreement of the teachers. *

YES

Participant Signature. Please type in your full name in lieu of a signature *

Date *

Submit

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PHYSICAL AND PSYCHOLOGICAL HISTORY

EMERGENCY CONTACT DETAILS

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