UAHLP Intake Form

Have you completed the Universal Consent Form?*

Name*

First Last

Date of Birth*

Phone

Email

Address*

Street Address Address Line 2 City Province Postal Code

Emergency Contact Name*

First Last

Emergency Contact Phone*

What is your relationship to your emergency contact?

Gender (check all that apply)*

Preferred Pronouns

First Language*

Second Language

Do you have any allergies?*

Please List your allergies

Do you have any Health Condition That Would Require Medication Being Administered During Programming?*

List the medications required and used:

Do you have any Medical or Health Issues That Can Impact Program Participation?*

Any Accommodations to Participate in Activities? If So, Please Describe:

Do you have diabetes?

Do you have a family history of diabetes?

Tobacco Relationship:*

Currently engages with commercial tobacco (Cigarettes, E-Cigarettes, Vaping Products etc.)
Currently engages with traditional tobacco practices and/or knowledge
None