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Pathways to Success in STEM

Health & Diet Questionnaire

 **Only students who have been accepted to the program via our application process may register! Please do not complete these forms if you have not been accepted to the program.

Forms will be available after May 8, 2018.

In the unlikely event of an accident or medical emergency, we need to have your medical information readily available. For this reason, it is critical to fill out the health and diet questionnaire thoroughly, indicating all current medications, past injuries, and any present conditions. This information is for the program’s files only and remains strictly confidential.  

 

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Look for it on your Admissions letter. If you can't find it, please enter "Don't Know."
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If you answered "yes", please describe in detail in the space provided below.
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If you answered "yes", please describe in detail in the space provided below.
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If you answered "yes", please describe in detail in the space provided below.
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If you answered "yes", please describe in detail in the space provided below.
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If you answered "yes", please describe in detail in the space provided below.
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If you answered "yes", please describe in detail in the space provided below.
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If you answered "yes", please describe in detail in the space provided below.
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If you answered "yes", please describe in detail in the space provided below.
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If no, please either complete the information below (some fields may not apply), email a scan of both sides of your card to outdoors@lclark.edu, or, if you are on campus, bring your medical insurance card to the College Outdoors office in Templeton 244.
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Pathways to Success in STEM

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