Apply here - Dose of the Coast

Dose of the Coast

Thank you for your interest in becoming a Dose of the Coast participant!

General Information:

This packet contains a Risk Advisory and Activity Consent Form. Please review these documents yourself, and bring the medical release form to your physician. Signed and completed forms should be turned into Dose of the Coast at least two weeks prior to the event. They must be emailed to ashley@doseofthecoast.org. Please include a paragraph describing how Dose of the Coast may be helpful to you in the email body. We look forward to seeing you on the water!

Dose of the Coast activities will take place outdoors. Whenever possible, events will be planned with an air-conditioned area close by.
Sun, rain, lightning, sea spray, seasickness, rough waters, slippery and wet decks all may be encountered while at an event.
Many events will take place on a boat, which will require participants to step on and off of.
Closed-toed shoes are mandatory.
An extra set of clothes to change into is suggested.
Illegal drugs are not allowed and intoxicated persons will not be allowed to participate.
All event activities are voluntary and can be terminated at any time by the participant.
Different cancer treatments affect the immune system differently. This is one of the reasons we ask Dose of the Coast participants to get medical clearance from their doctor. Please be sure to address all of your concerns with your doctor or Dose of the Coast staff.
Meals may be provided, based on the event planned.
Consuming raw or undercooked seafood, such as fish or shellfish, brought home from an event may increase your risk of foodborne illness.

I have read and understand the above information:(Required)

Name:(Required)

First Last

Date(Required)

Dose of the Coast Event Risk Advisory to Health-Care Providers, Participants, and Family

Coastal Experience.

Participation in any Dose of the Coast events or in any Coastal, water-based, activity can be potentially physically, mentally, and emotionally demanding. Each coastal adventure offers a unique experience that is not risk-free. Knowledgeable staff will instruct all participants in safety measures to be followed. Be prepared to listen to and carefully follow these safety measures and to accept responsibility for the health and safety of yourself and others.

Coastal Experience Requirements.

Each person must be able to lift a minimum of 20lbs to participate in the fishing portion of the event. Although it will be avoided as much as possible, there will be potentially rough, wet, and muddy conditions. These conditions can potentially lead to tripping, slipping, and falling. All participants must wear closed-toed shoes while on the boats. Long sleeve shirts and long pants are recommended to prevent scrapes on arms and legs, and sunburn. Climatic condition averages can range from 47-62 in winter (December-January), 65 to 70 degrees in the spring (February-April), 60-100+ in summer (May-August), and 53-87 degrees in fall (September-November). Each person should be prepared for hot sunny conditions or cool-er windy conditions, depending on the season, and always be prepared for potentially rainy conditions. Shade will be provided as often as possible and events will be planned around good-weather conditions, but often, weather can change unexpectedly. Water will be provided throughout the entire event, and hydration will be encouraged. Refer to the Dose of the Coast website, doseofthecoast.org, for more information.

Be prepared.

While participating in a Dose of the Coast event, provided life jackets must be worn at all times when on the water. Crew members travel together at all times. Emergency communications via radio and cell phone will be provided by boat captains and Dose of the Coast staff. Radio communication and/or emergency evacuation can be hampered by weather, terrain, distance, time of day, equipment malfunction, and other factors, and are not a substitute for taking appropriate precautions and having adequate first-aid knowledge and equipment. Please call Dose of the Coast at 504-641-4629 if you have any questions.

Seizures (Epilepsy).

The seizure disorder must be well-controlled by medication. A well-controlled disorder is one in which a year has passed without a seizure. Exceptions to this guideline may be considered on an individual basis and will be based on the specific type of seizure and likely risks to the individual and/or other members of the crew.

Diabetes Mellitus.

Both the person with diabetes and one other person in the group need to be able to recognize signs of excessively high or low blood sugar and adjust the dose of insulin. An insulin-de-pendent person who was diagnosed or who has had a change in the delivery system (e.g., insulin pump) in the last six months is advised not to participate. A person with diabetes who has had frequent hospitalizations or who has had problems with low blood sugar should not participate until better control of diabetes has been achieved.

Asthma.

Asthma must be well-controlled before participating. This means: 1) the use of a rescue in-haler (albuterol) less than two times per week (ex-cept use for the prevention of exercise- induced asthma); 2) nighttime awakenings for asthma symp-toms less than two times per month. Well-controlled asthma may include the use of long-acting bron-chodilators, inhaled steroids, or oral medications such as Singulair. You may not be allowed to partici-pate if: 1) you have asthma not controlled by med-ication; or 2) you have been hospitalized/gone to the emergency room to treat asthma in the past six months; or 3) you have needed treatment by oral steroids (prednisone) in the past six months. You must bring an ample supply of your medication and a spare rescue inhaler that are not expired. At least one other member of the crew should know how to use the rescue inhaler. Any person who has needed treatment for asthma in the past three years must carry a rescue inhaler to Dose of the Coast events. If you do not bring a rescue inhaler, you must buy one before you will be allowed to participate.

Allergy or Anaphylaxis.

People who have had an anaphylactic reaction from any cause will be required to keep appropriate treatment with them. You and at least one other member of your crew must know how to give the treatment. If you do not bring appropriate treatment with you, you will be required to buy it before you will be allowed to participate.

Recent Musculoskeletal Injuries and Orthopedic Surgery.

Participants will put some amount of strain on their joints when reeling in fish and getting in and out of vessels. Wave action can put pressure on the back and joints. Individuals who have significant musculoskeletal problems (including back problems) or have had orthopedic surgery or injuries within the last six months must have a letter of clearance from their treating physician to be considered for ap-proval, and Dose of the Coast should be contacted in advance of participation. Permission is not guar-anteed.

Psychological and Emotional Difficulties.

Participants and guardians should be aware that no coastal adventure experience is designed to assist participants in overcoming psychological or emotional problems. These problems can potentially become worse when a participant is under stress from physical exertion. Medication must never be stopped prior to participation and should be continued throughout the entire experience.

Cardiac or Cardiovascular Disease.

Adults or youth who have a history of chest pain, myocardial infarction (heart attack), a family history of premature heart disease, or heart surgery including angioplasty may consider a physician-supervised stress test. Even if the stress test results are normal, the testing is not done in field conditions. If the results are abnormal, the individual is advised not to participate. Hospitalization within the last 6 months due to heart disease should not participate.

Suppressed Immune System.

Vibrio is a bacteria that thrives in brackish and saltwater. It is a risk for everyone, but infection risk is higher for those with liver disease, cancer, diabetes, HIV, or thalassemia. If you receive immune-suppressing therapy for disease treatment or take medicine to reduce stomach acid or have had stomach surgery recently, you are at a higher risk. Every precaution to prevent infection will be taken, such as washing hands frequently, wearing waterproof bandages over open wounds, and handling fish with protective gloves, and bleach dip.

Medication.

Each participant who needs medication must bring enough medication for the duration of the trip, as well as enough to store two supplies in two separate locations. Due to the possibility of bags and equipment getting wet, every attempt is made to store medications in two separate packs in different locations.

Weight Limits.

Each participant in a Dose of the Coast event should not exceed the maximum acceptable weight of 295 lbs. Those who fall within the recommended weight limits are much more likely to have an enjoyable trek and avoid incurring injuries and other health risks.

I have read and understand the risks associated with participating in Dose of the Coast events:(Required)

Name:(Required)

First Last

Activity Consent Form

Part A: Informed Consent, Release Agreement, and Authorization

Full Name:(Required)

First Last

Date of Birth:(Required)

I understand that participation in Dose of the Coast activities involves the risk of personal injury, including death, due to the physical, mental, and emotional challenges in the activities offered. Information about those activities may be obtained from the venue or activity coordinators. I also understand that participation in these activities is entirely voluntary and requires participants to follow instructions and abide by all applicable rules and standards of conduct.

In case of an emergency involving me or my family member, I understand that efforts will be made to contact the individual listed as the emergency contact person by the medical provider and/or event leader. In the event that this person cannot be reached, permission is hereby given to the medical provider selected by the event leader in charge to secure proper treat-ment, including hospitalization, anesthesia, surgery, or injections of medication for me or my family member. Medical providers are authorized to disclose protected health information to the person in charge, on-site medical staff, event management, and/or any physician or health-care provider involved in providing medical care to the participant. Protected Health Information/ Confidential Health Information (PHI/CHI) under the Standards for Privacy of Individually Identifiable Health Information, 45 C.F.R. §§160.103, 164.501, etc. seq., as amended from time to time, includes examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant or participant’s parents and/or guardian, and/or determination of the partici-pant’s ability to continue in the program activities.

I have carefully considered the risk involved and hereby give my informed consent to participate (or my family member to participate) in all activities offered in the program. I further authorize the sharing of the information on this form with any Dose of the Coast volunteers or professionals who need to know of medical conditions that may require special consideration in conducting event activities.

With appreciation of the dangers and risks associated with programs and activities, on my own behalf and/or on behalf of my child, I hereby fully and completely release and waive any and all claims for personal injury, death, or loss that may arise against Dose of the Coast, the local council, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with any program or activity.

I also hereby assign and grant to the local council and Dose of the Coast, as well as their authorized representatives, the right and permission to use and publish the photographs/film/video-tapes/electronic representations and/or sound recordings made of me or my family member at all Dose of the Coast activities, and I hereby release Dose of the Coast, the local council, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with the activity from any and all liability from such use and publication. I further authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said photographs/film/videotapes/electronic representations and/or sound recordings without limitation at the discretion of Dose of the Coast, and I specifically waive any right to any compensation I may have for any of the foregoing.

NOTE: Due to the nature of programs and activities, Dose of the Coast and local councils cannot continually monitor compliance of program participants or any limitations imposed upon them by caregivers or medical providers. However, so that leaders can be as familiar as possible with any limitations, list any restrictions imposed on a participant in connection with programs or activities below.

List participant restrictions, if any:

I understand that, if any information I/we have provided is found to be inaccurate, it may limit and/or eliminate the opportunity for participation in any event or activity. If I am participating in a fishing, canoeing, kayaking, sailing event, meals, or any other associated activity, I have also read and understand the supplemental risk advisories and understand that I will not be allowed to participate in applicable programs if those requirements are not met. The participant has permission to engage in all activities described, except as specifically noted by myself or the healthcare provider. If the participant is under the age of 18, a parent or guardian’s signature is required.

Participant's Signature:(Required)

Date:(Required)

Parent/Guardian signature for youth (under 18):

Date:

Part B: General Information/Health History (to be filled by participant)

Name:(Required)

First Last

Date of Birth:(Required)

Email:(Required)

Event Title (fishing, sailing, sunset, etc.):(Required)

Shirt Size:(Required)

Number of guests:(Required)

Age:(Required)

Gender:(Required)

Height (inches):(Required)

Weight (lbs.):(Required)

Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you have health insurance?(Required)

Yes

Health/Accident Insurance Company:

Policy No:

Please attach a photocopy of both sides of the insurance card. If you do not have medical insurance, enter “no” above.

Max. file size: 2 GB.

In case of emergency, notify the person below:

Name:(Required)

First Last

Relationship:(Required)

Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mobile phone:(Required)

Other Phone:(Required)

Alternate Contact's Name:(Required)

First Last

Alternate's Phone:(Required)

Health History
Do you currently have or have you ever been treated for any of the following?

Diabetes:(Required)

Yes

Explain (last HbA1c percentage and date):

Hypertension (high blood pressure):(Required)

Yes

Explain (last hospitalization date):

Family history of heart disease or any sudden heart-related death of a family member before age 50:(Required)

Yes

Explain:

Asthma:(Required)

Yes

Explain (last attack date):

Lung/respiratory diasease:(Required)

Yes

Explain:

COPD:(Required)

Yes

Explain:

Ear/eyes/nose/sinus problems:(Required)

Yes

Explain:

Muscular/skeletal condition/muscle or bone issues:(Required)

Yes

Explain:

Head injury/concussion:(Required)

Yes

Explain:

Sea sickness:(Required)

Yes

Explain:

Psychiatric/psychological or emotional difficulties:(Required)

Yes

Explain:

Behavioral/neurological disorders:(Required)

Yes

Explain:

Blood disorders/sickle cell disease:(Required)

Yes

Explain:

Fainting spells and dizziness:(Required)

Yes

Explain:

Kidney disease:(Required)

Yes

Explain:

Seizures:(Required)

Yes

Explain (last seizure date):

Abdominal/stomach/digestive problems:(Required)

Yes

Explain:

Thyroid disease:(Required)

Yes

Explain:

Excessive fatigue:(Required)

Yes

Explain:

Obstructive sleep apnea/sleep disorders:(Required)

Yes

CPAP:(Required)

Yes

List all surgeries and hospitalizations and dates for each (if applicable):

List any other medical conditions not listed above:

Part B: General Information/Health History

Name:(Required)

First Last

Date of Birth:(Required)

Allergies/Medications
Are you allergic to or do you have any adverse reaction to the following?

Medication:(Required)

Yes

Explain:

Food/Shellfish:(Required)

Yes

Explain:

Plants:(Required)

Yes

Explain:

Insect bites/stings:(Required)

Yes

Explain:

Animals (specifically dogs):(Required)

Yes

Explain:

CHECK 'NO" IF NO MEDICATIONS ARE ROUTINELY TAKEN.(Required)

Yes

List all medications currently used, including any over-the-counter medications:

Non-prescription medication administration is authorized with these exceptions:

Administration of the above medication is approved for participant by:

Participant Signature, or Parent/Guardian if under 18:(Required)

MD/DO, NP, or PA signature (if required)

Max. file size: 2 GB.

Bring enough medications in sufficient quantities and in the original containers. Make sure that they are NOT expired, including inhalers and EpiPens. You SHOULD NOT STOP taking any maintenance medication unless instructed to do so by your doctor.

Part B: General Information/Health History

Immunization.
The following immunizations are recommended by Dose of the Coast. Tetanus immunization is required and must have been received within the last 10 years. If you had the disease, check the disease column and list the date. If immunized, check yes and provide the year received. This information may need to be completed by your healthcare provider.

Tetanus/Pertussis/Diphtheria:(Required)

Yes

Immunization Date:

Pneumovax:(Required)

Yes

Immunization Date:

Measles/mumps/rubella:(Required)

Yes

Immunization Date:

Polio:(Required)

Yes

Immunization Date:

Chicken Pox/Varicella Zoster:(Required)

Yes

Immunization Date:

Hepatitis B:(Required)

Yes

Immunization Date:

Meningitis:(Required)

Yes

Immunization Date:

Influenza:(Required)

Yes

Immunization Date:

Other (i.e., HIB):(Required)

Yes

Immunization Date:

Exemption to immunizations (upload required):

Max. file size: 2 GB.

Please list any additional info about your medical history:

Part C: Pre-Participation Physical (*REQUIRED*)

This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants.

Download this form to be completed by physician.

Upload Signed Form(Required)

Max. file size: 2 GB.

If this application is for a fishing-related event and you DO NOT have a fishing license, please fill out the following information:

Name:

First Last

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth:

Email address:

Cell Phone Number:

Cell phone company (AT&T, Verizon, etc.)

Date

Thank you!