Gerald Island April 2024 | Medical Form

Gerald Island September 2025 | Volunteer Medical For

Please complete this form prior to your arrival to Gerald Island. Our stewardship team will be notified once the form is completed.

Volunteer's Name *

First

Last

Email *

Sex

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Emergency contact (inc. name, phone number, and relationship) *

DOCTOR'S DETAILS

Doctor Name

First

Last

If you do not have a family doctor, you can fill this section with 'no current doctor'.

Doctor's Phone Number

Doctor's Healthcare Facility Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

MEDICAL HISTORY

Are you curently receiving medical treatment? *

Are you currently taking any medication? *

Have you ever suffered a serious illness or injury? *

Do you have any allergies (food, insects, medications)? *

Any other disabilities or conditions not mentioned above? *

Have you had medical care in the last three months? *

If 'yes' describe the care.

Medical History Terms & Conditions *

Terms and Conditions

1. YOUR AGREEMENT

By agreeing to this release form, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use tick the box.

PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.

Patient/Carer/Guardian Signature *

Clear Signature

Date *

Gerald Island September 2025 | Volunteer Medical For

DOCTOR'S DETAILS

MEDICAL HISTORY

About

Find

Join Our Community

Get the latest marine recreation & conservation news. Please put in your first and last name plus email to receive our newsletters.

3285 Roper Road
Ladysmith, BC, V9G 1C4
Contact Us

We are a nonprofit organization and a registered charity (CRA number: 812142826RR0001). Income tax receipts will be issued by Canada Helps upon donation.

Gerald Island September 2025 | Volunteer Medical For

DOCTOR'S DETAILS

MEDICAL HISTORY

About

Find

Join Our Community

Get the latest marine recreation & conservation news. Please put in your first and last name plus email to receive our newsletters.

3285 Roper RoadLadysmith, BC, V9G 1C4Contact Us

We are a nonprofit organization and a registered charity (CRA number: 812142826RR0001). Income tax receipts will be issued by Canada Helps upon donation.

3285 Roper Road
Ladysmith, BC, V9G 1C4
Contact Us