2025 FUSE Participant Application GENERAL INFORMATION - ALL INFORMATION WILL BE KEPT STRICTLY CONFIDENTIAL Question Title * 1. ABOUT YOU! Your Full Name Mailing Address - number & street City State Zip Code Home Phone Cell Phone Email Address Height Weight Sex Question Title * 2. T-shirt Size (adult shirt sizes) Small Medium Large Extra-Large 2XLarge 3XLarge 4XLarge 5XLarge Question Title * 3. MEDICAL INSURANCE COVERAGE & ACKNOWLEDGMENT: By my signature on this application, I agree to be responsible for any medical expenses I incur through participation in the FUSE Retreat. I also release the FUSE Foundation from any liability for injuries I may incur during the Retreat. I do NOT have medical insurance I DO have medical insurance Question Title * 4. MEDICAL INSURANCE COVERAGE Company Name (Blue Cross/Shield, Medicaid, etc.) Policy holder's Name Policy / Group Number Question Title * 5. GENERAL MEDICAL INFORMATION Primary Care Physician Name Physician Address Physician Phone Please list any food allergies and type of reaction Please list any dietary restrictions (vegetarian? gluten free? etc.) Some Retreat participants may be accompanied by a service dog. Please indicate any type of adverse reaction you may have so appropriate action can be taken. Question Title * 6. Have you seen a Psychiatrist or Psychologist in the last 3 years? Yes No If yes, why? Question Title * 7. Are you being followed by a Psychiatrist or Psychologist for any acute or chronic condition? Yes No If yes, why? Question Title * 8. Do you currently have a communicable / infectious disease, or have you been exposed to one in the past six months? Yes No If yes, what? Question Title * 9. IMMUNIZATIONS: As our FUSE participants may be medically fragile, an up-to-date immunization status is HIGHLY RECOMMENDED to attend the FUSE Retreat. Please consider this as you prepare to attend. And, if you develop any symptoms that could place others at risk, please notify Retreat staff immediately (whether before you arrive, or while you are at Retreat). By marking "Yes", you acknowledge that immunizations are highly recommended for the FUSE Retreat. Yes No Next
