%PDF-1.4 % 15 0 obj <>/P 2 0 R/MK<<>>/Parent 14 0 R/F 4/DA(/Helv 10 Tf 0 g)/Subtype/Widget/Rect[98.04 716.76 334.44 734.04]>> endobj 17 0 obj <
>/Parent 14 0 R/F 4/DA(/Helv 10 Tf 0 g)/Subtype/Widget/Rect[97.7822 715.615 334.182 732.895]>> endobj 18 0 obj <>/Parent 14 0 R/F 4/DA(/Helv 10 Tf 0 g)/Subtype/Widget/Rect[98.6516 715.615 335.052 732.895]>> endobj 19 0 obj <>/Parent 14 0 R/F 4/DA(/Helv 10 Tf 0 g)/Subtype/Widget/Rect[99.0027 702.224 335.403 719.504]>> endobj 14 0 obj <> endobj 21 0 obj <>/P 2 0 R/MK<<>>/Parent 20 0 R/F 4/DA(/Helv 10 Tf 0 g)/Subtype/Widget/Rect[108.96 695.76 334.56 713.04]>> endobj 23 0 obj <>/Parent 20 0 R/F 4/DA(/Helv 10 Tf 0 g)/Subtype/Widget/Rect[108.702 694.615 334.302 711.895]>> endobj 24 0 obj <>/Parent 20 0 R/F 4/DA(/Helv 10 Tf 0 g)/Subtype/Widget/Rect[109.572 694.615 335.172 711.895]>> endobj 25 0 obj <>/Parent 20 0 R/F 4/DA(/Helv 10 Tf 0 g)/Subtype/Widget/Rect[109.923 681.224 335.523 698.504]>> endobj 20 0 obj <> endobj 26 0 obj <>/TU(Expedition/crew No)>> endobj 28 0 obj <>/TU(or staff position)>> endobj 30 0 obj <>/T(Checking this box indicates you DO NOT want your child to use a BB device)/Subtype/Widget/Rect[321.12 496.32 329.16 502.56]/FT/Btn/P 2 0 R/AS/Off/DA(/ZaDb 0 Tf 0 g)/AP<>/D<>>>/TU(Checking this box indicates you DO NOT want your child to use a BB device)>> endobj 34 0 obj <>/T(None)/Subtype/Widget/Rect[483.12 419.16 489.36 425.029]/FT/Btn/P 2 0 R/AS/Off/DA(/ZaDb 0 Tf 0 g)/AP<>/D<>>>/TU(None)>> endobj 38 0 obj <>/TU(List participant restrictions, if any)>> endobj 41 0 obj <>/P 2 0 R/MK<<>>/Parent 40 0 R/F 4/DA(/Helv 0 Tf 0 g)/Subtype/Widget/Rect[121.49 314.008 442.142 330.34]>> endobj 42 0 obj <>/Subtype/Widget/Rect[61.66 96.15 422.8 108]/DA(/TimesNewRomanPSMT 10 Tf 0 0 0 rg )/P 6 0 R/Parent 40 0 R/BS<>/AP<>>> endobj 40 0 obj <> endobj 44 0 obj <>/TU(Date)>> endobj 46 0 obj <>/T(Signature2)/Subtype/Widget/Rect[155.347 296.083 441.479 313.079]/FT/Sig/P 2 0 R/DA(/Helv 0 Tf 0 g )/AP<>>> endobj 47 0 obj <>/TU(Date)>> endobj 49 0 obj <>/TU(Name)>> endobj 51 0 obj <>/TU(Phone)>> endobj 53 0 obj <>/TU(Name)>> endobj 55 0 obj <>/TU(Phone)>> endobj 57 0 obj <>/TU(Name)>> endobj 59 0 obj <>/TU(Phone)>> endobj 61 0 obj <>/TU(Name)>> endobj 63 0 obj <>/TU(Phone)>> endobj 65 0 obj <>/TU(Expedition/crew No)>> endobj 67 0 obj <>/TU(or staff position)>> endobj 69 0 obj <>/TU(Age)>> endobj 71 0 obj <>/TU(Gender)>> endobj 73 0 obj <>/TU(Height \(inches)>> endobj 75 0 obj <>/TU(Weight \(lbs)>> endobj 77 0 obj <>/TU(Address)>> endobj 79 0 obj <>/TU(City)>> endobj 81 0 obj <>/TU(State)>> endobj 83 0 obj <>/TU(ZIP code)>> endobj 85 0 obj <>/TU(Phone)>> endobj 87 0 obj <>/TU(Unit leader)>> endobj 89 0 obj <>/TU(Unit leaders mobile)>> endobj 91 0 obj <>/TU(Council Name/No)>> endobj 93 0 obj <>/TU(Unit No)>> endobj 95 0 obj <>/TU(Health/Accident Insurance Company)>> endobj 97 0 obj <>/TU(Policy No)>> endobj 99 0 obj <>/TU(Name)>> endobj 101 0 obj <>/TU(Relationship)>> endobj 103 0 obj <>/TU(Address)>> endobj 105 0 obj <>/TU(Home phone)>> endobj 107 0 obj <>/TU(Other phone)>> endobj 109 0 obj <>/TU(Alternate contact name)>> endobj 111 0 obj <>/TU(Alternates phone)>> endobj 114 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[59.12 440.908 71.0723 451.602]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 113 0 R/AS/Off/BS<>>> endobj 119 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[81.4648 440.581 93.3658 451.564]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 113 0 R/AS/Off/BS<>>> endobj 113 0 obj <> endobj 124 0 obj <>/T(Last HbA1c)/Subtype/Widget/Rect[372.304 439.594 460.275 451.638]/FT/Tx/P 3 0 R/DA(/Helv 12 Tf 0 g)>> endobj 126 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[511.417 441.651 520.805 451.201]/DA(/Helv 0 Tf 0 g )/P 3 0 R/Parent 125 0 R/AS/Off/BS<>>> endobj 131 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[532.799 442.474 542.399 451.637]/DA(/Helv 0 Tf 0 g )/P 3 0 R/Parent 125 0 R/AS/Off/BS<>>> endobj 125 0 obj <> endobj 137 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[59.12 426.607 71.0723 437.301]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 136 0 R/AS/Off/BS<>>> endobj 143 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[81.4648 426.28 93.3658 437.263]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 136 0 R/AS/Off/BS<>>> endobj 136 0 obj <> endobj 148 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(Last HbA1c percentage and date Insulin pump Yes NoHypertension high blood pressure)/Subtype/Widget/Rect[272.64 424.8 575.28 438.24]/FT/Tx/P 3 0 R/Q 1/TU(Last HbA1c percentage and date: Insulin pump: Yes No_Hypertension \(high blood pressure\))>> endobj 151 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[59.12 404.546 71.0723 415.24]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 150 0 R/AS/Off/BS<>>> endobj 156 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[81.4648 404.874 93.3658 415.857]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 150 0 R/AS/Off/BS<>>> endobj 150 0 obj <> endobj 162 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(Last HbA1c percentage and date Insulin pump Yes NoAdult or congenital heart diseaseheart attackchest pain angina heart murmurcoronary artery disease Any heart surgery or procedure Explain all yes answers)/Subtype/Widget/Rect[273.12 396.84 574.8 423.36]/FT/Tx/P 3 0 R/Q 1/TU(Last HbA1c percentage and date: Insulin pump: Yes No_Adult or congenital heart disease/heart attack/chest pain \(angina\)/ heart murmur/coronary artery disease. Any heart surgery or procedure. Explain all yes answers.)>> endobj 165 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[58.4655 381.349 70.4178 392.044]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 164 0 R/AS/Off/BS<>>> endobj 171 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[80.8103 381.021 92.7113 392.004]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 164 0 R/AS/Off/BS<>>> endobj 164 0 obj <> endobj 177 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(Last HbA1c percentage and date Insulin pump Yes NoFamily history of heart disease or any sudden heartrelated death of a family member before age 50)/Subtype/Widget/Rect[272.88 376.92 575.04 395.64]/FT/Tx/P 3 0 R/Q 1/TU(Last HbA1c percentage and date: Insulin pump: Yes No_Family history of heart disease or any sudden heart-related death of a family member before age 50.)>> endobj 180 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[58.968 363.952 70.9203 374.646]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 179 0 R/AS/Off/BS<>>> endobj 186 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[80.9855 363.952 92.8865 374.935]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 179 0 R/AS/Off/BS<>>> endobj 179 0 obj <> endobj 192 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(Last HbA1c percentage and date Insulin pump Yes NoStrokeTIA)/Subtype/Widget/Rect[272.64 362.52 575.28 375.96]/FT/Tx/P 3 0 R/Q 1/TU(Last HbA1c percentage and date: Insulin pump: Yes No_Stroke/TIA)>> endobj 195 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[58.968 349.324 70.9203 360.018]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 194 0 R/AS/Off/BS<>>> endobj 200 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[80.9855 349.324 92.8865 360.307]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 194 0 R/AS/Off/BS<>>> endobj 194 0 obj <> endobj 205 0 obj <>/T(Last Attack Date)/Subtype/Widget/Rect[325.963 348.556 575.345 362.956]/FT/Tx/P 3 0 R/DA(/Helv 0 Tf 0 g )>> endobj 207 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[58.968 335.036 70.9203 345.73]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 206 0 R/AS/Off/BS<>>> endobj 213 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[80.9855 335.036 92.8865 346.019]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 206 0 R/AS/Off/BS<>>> endobj 206 0 obj <> endobj 219 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(Last attack dateLungrespiratory disease)/Subtype/Widget/Rect[272.64 333.72 575.28 347.16]/FT/Tx/P 3 0 R/Q 1/TU(Last attack date:_Lung/respiratory disease)>> endobj 222 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[58.968 320.735 70.9203 331.429]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 221 0 R/AS/Off/BS<>>> endobj 228 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[80.9855 320.735 92.8865 331.718]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 221 0 R/AS/Off/BS<>>> endobj 221 0 obj <> endobj 234 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(Last attack dateCOPD)/Subtype/Widget/Rect[272.64 319.32 575.28 332.76]/FT/Tx/P 3 0 R/Q 1/TU(Last attack date:_COPD)>> endobj 237 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[58.968 306.12 70.9203 316.814]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 236 0 R/AS/Off/BS<>>> endobj 243 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[80.9855 306.12 92.8865 317.103]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 236 0 R/AS/Off/BS<>>> endobj 236 0 obj <> endobj 249 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(Last attack dateEareyesnosesinus problems)/Subtype/Widget/Rect[272.64 304.92 575.28 318.36]/FT/Tx/P 3 0 R/Q 1/TU(Last attack date:_Ear/eyes/nose/sinus problems)>> endobj 252 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[58.968 292.053 70.9203 302.747]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 251 0 R/AS/Off/BS<>>> endobj 258 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[80.9854 292.053 92.8864 303.036]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 251 0 R/AS/Off/BS<>>> endobj 251 0 obj <> endobj 264 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(Last attack dateMuscularskeletal conditionmuscle or bone issues)/Subtype/Widget/Rect[272.64 290.52 575.28 303.96]/FT/Tx/P 3 0 R/Q 1/TU(Last attack date:_Muscular/skeletal condition/muscle or bone issues)>> endobj 267 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[58.968 277.765 70.9203 288.459]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 266 0 R/AS/Off/BS<>>> endobj 273 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[80.9854 277.765 92.8864 288.748]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 266 0 R/AS/Off/BS<>>> endobj 266 0 obj <> endobj 279 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(Last attack dateHead injuryconcussionTBI)/Subtype/Widget/Rect[272.64 276.24 575.28 289.56]/FT/Tx/P 3 0 R/Q 1/TU(Last attack date:_Head injury/concussion/TBI)>> endobj 282 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[58.968 263.477 70.9203 274.171]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 281 0 R/AS/Off/BS<>>> endobj 288 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[80.9854 263.477 92.8864 274.46]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 281 0 R/AS/Off/BS<>>> endobj 281 0 obj <> endobj 294 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(Last attack dateAltitude sickness)/Subtype/Widget/Rect[272.64 261.84 575.28 275.28]/FT/Tx/P 3 0 R/Q 1/TU(Last attack date:_Altitude sickness)>> endobj 297 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[58.968 249.189 70.9203 259.883]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 296 0 R/AS/Off/BS<>>> endobj 303 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[80.9854 249.189 92.8864 260.172]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 296 0 R/AS/Off/BS<>>> endobj 296 0 obj <> endobj 309 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(Last attack datePsychiatricpsychological or emotional difficulties)/Subtype/Widget/Rect[272.64 247.44 575.28 260.88]/FT/Tx/P 3 0 R/Q 1/TU(Last attack date:_Psychiatric/psychological or emotional difficulties)>> endobj 312 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[58.968 234.901 70.9203 245.595]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 311 0 R/AS/Off/BS<>>> endobj 318 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[80.9854 234.901 92.8864 245.884]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 311 0 R/AS/Off/BS<>>> endobj 311 0 obj <> endobj 324 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(Last attack dateNeurologicalbehavioral disorders)/Subtype/Widget/Rect[272.64 233.04 575.28 246.48]/FT/Tx/P 3 0 R/Q 1/TU(Last attack date:_Neurological/behavioral disorders)>> endobj 327 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[58.968 220.273 70.9203 230.967]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 326 0 R/AS/Off/BS<>>> endobj 333 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[80.9854 220.273 92.8864 231.256]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 326 0 R/AS/Off/BS<>>> endobj 326 0 obj <> endobj 339 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(Last attack dateBlood disorderssickle cell disease)/Subtype/Widget/Rect[272.64 218.64 575.28 232.08]/FT/Tx/P 3 0 R/Q 1/TU(Last attack date:_Blood disorders/sickle cell disease)>> endobj 342 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[59.2952 205.44 71.2475 216.134]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 341 0 R/AS/Off/BS<>>> endobj 348 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[81.3127 205.44 93.2137 216.423]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 341 0 R/AS/Off/BS<>>> endobj 341 0 obj <> endobj 354 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(Last attack dateFainting spells and dizziness)/Subtype/Widget/Rect[272.64 204.24 575.28 217.68]/FT/Tx/P 3 0 R/Q 1/TU(Last attack date:_Fainting spells and dizziness)>> endobj 357 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[59.2952 191.152 71.2475 201.846]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 356 0 R/AS/Off/BS<>>> endobj 363 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[81.3127 191.152 93.2137 202.135]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 356 0 R/AS/Off/BS<>>> endobj 356 0 obj <> endobj 369 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(Last attack dateKidney disease)/Subtype/Widget/Rect[272.64 189.84 575.28 203.28]/FT/Tx/P 3 0 R/Q 1/TU(Last attack date:_Kidney disease)>> endobj 372 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[59.2952 176.864 71.2475 187.558]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 371 0 R/AS/Off/BS<>>> endobj 378 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[81.3127 176.864 93.2137 187.847]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 371 0 R/AS/Off/BS<>>> endobj 371 0 obj <> endobj 384 0 obj <>/T(Last Seizure Date)/Subtype/Widget/Rect[326.618 175.091 575.672 190.146]/FT/Tx/P 3 0 R/DA(/Helv 0 Tf 0 g )>> endobj 386 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[59.2952 162.236 71.2475 172.93]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 385 0 R/AS/Off/BS<>>> endobj 392 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[81.3127 162.236 93.2137 173.219]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 385 0 R/AS/Off/BS<>>> endobj 385 0 obj <> endobj 398 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(Last seizure dateAbdominalstomachdigestive problems)/Subtype/Widget/Rect[272.64 161.04 575.28 174.48]/FT/Tx/P 3 0 R/Q 1/TU(Last seizure date:_Abdominal/stomach/digestive problems)>> endobj 401 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[59.2952 147.948 71.2475 158.642]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 400 0 R/AS/Off/BS<>>> endobj 407 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[81.3127 147.948 93.2137 158.931]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 400 0 R/AS/Off/BS<>>> endobj 400 0 obj <> endobj 413 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(Last seizure dateThyroid disease)/Subtype/Widget/Rect[272.64 146.64 575.28 160.08]/FT/Tx/P 3 0 R/Q 1/TU(Last seizure date:_Thyroid disease)>> endobj 416 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[59.2952 133.32 71.2475 144.014]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 415 0 R/AS/Off/BS<>>> endobj 422 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[81.3127 133.32 93.2137 144.303]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 415 0 R/AS/Off/BS<>>> endobj 415 0 obj <> endobj 428 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(Last seizure dateSkin issues)/Subtype/Widget/Rect[272.64 132.24 575.28 145.68]/FT/Tx/P 3 0 R/Q 1/TU(Last seizure date:_Skin issues)>> endobj 431 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[59.2952 119.032 71.2475 129.726]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 430 0 R/AS/Off/BS<>>> endobj 436 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[81.3127 119.032 93.2137 130.015]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 430 0 R/AS/Off/BS<>>> endobj 430 0 obj <> endobj 442 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[304.145 120.438 312.872 129.602]/DA(/ZaDb 0 Tf 0 g)/P 3 0 R/Parent 441 0 R/AS/Off/BS<>>> endobj 447 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[327.708 120.002 336.872 130.474]/DA(/ZaDb 0 Tf 0 g)/P 3 0 R/Parent 441 0 R/AS/Off/BS<>>> endobj 441 0 obj <> endobj 452 0 obj <>/TU(CPAP: Yes No)>> endobj 455 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[59.2952 104.58 71.2475 115.274]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 454 0 R/AS/Off/BS<>>> endobj 461 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[81.3127 104.58 93.2137 115.563]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 454 0 R/AS/Off/BS<>>> endobj 454 0 obj <> endobj 467 0 obj <>/T(Last surgery date)/Subtype/Widget/Rect[328.582 103.091 575.672 117.819]/FT/Tx/P 3 0 R/DA(/Helv 0 Tf 0 g )>> endobj 469 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[59.2952 90.2923 71.2475 100.987]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 468 0 R/AS/Off/BS<>>> endobj 475 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[81.3127 90.2923 93.2137 101.275]/DA(/ZaDb 12 Tf 0 g)/P 3 0 R/Parent 468 0 R/AS/Off/BS<>>> endobj 468 0 obj <> endobj 481 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(Last surgery dateList any other medical conditions not covered above)/Subtype/Widget/Rect[272.64 88.68 575.28 102.48]/FT/Tx/P 3 0 R/Q 1/TU(Last surgery date:_List any other medical conditions not covered above)>> endobj 483 0 obj <>/TU(Expedition/crew No)>> endobj 485 0 obj <>/TU(or staff position)>> endobj 488 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[212.939 652.255 222.545 661.206]/DA(/Helv 0 Tf 0 g )/P 4 0 R/Parent 487 0 R/AS/Off/BS<>>> endobj 493 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[261.703 651.927 270.982 660.879]/DA(/Helv 0 Tf 0 g )/P 4 0 R/Parent 487 0 R/AS/Off/BS<>>> endobj 487 0 obj <> endobj 498 0 obj <>/TU(AUTOINJECTOR? Exp. date \(if yes)>> endobj 501 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[496.41 652.255 505.963 661.534]/DA(/ZaDb 12 Tf 0 g)/P 4 0 R/Parent 500 0 R/AS/Off/BS<>>> endobj 506 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[542.936 652.458 552.109 661.251]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 500 0 R/AS/Off/BS<>>> endobj 500 0 obj <> endobj 511 0 obj <>/TU(INHALER? Exp. date \(if yes)>> endobj 514 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[58.9784 584.067 71.3228 595.314]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 513 0 R/AS/Off/BS<>>> endobj 519 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[80.1009 583.792 92.7196 595.314]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 513 0 R/AS/Off/BS<>>> endobj 513 0 obj <> endobj 524 0 obj <>/TU(Medication)>> endobj 527 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[59.1707 569.979 71.7379 581.499]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 526 0 R/AS/Off/BS<>>> endobj 532 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[79.5925 569.455 92.6833 581.499]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 526 0 R/AS/Off/BS<>>> endobj 526 0 obj <> endobj 537 0 obj <>/TU(Food)>> endobj 540 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[321.512 584.117 335.192 596.161]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 539 0 R/AS/Off/BS<>>> endobj 545 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[344.028 584.117 357.053 595.637]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 539 0 R/AS/Off/BS<>>> endobj 539 0 obj <> endobj 550 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(ExplainPlants)/Subtype/Widget/Rect[448.2 583.2 575.4 596.28]/FT/Tx/P 4 0 R/Q 1/TU(Explain_Plants)>> endobj 553 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[321.512 569.979 334.864 581.499]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 552 0 R/AS/Off/BS<>>> endobj 558 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[343.504 568.932 357.053 581.499]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 552 0 R/AS/Off/BS<>>> endobj 552 0 obj <> endobj 563 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(ExplainInsect bitesstings)/Subtype/Widget/Rect[448.2 568.44 575.4 582.24]/FT/Tx/P 4 0 R/Q 1/TU(Explain_Insect bites/stings)>> endobj 565 0 obj <>/T(Check here if no medications are routinely taken)/Subtype/Widget/Rect[53.88 537.96 62.76 544.44]/FT/Btn/P 4 0 R/AS/Off/DA(/ZaDb 0 Tf 0 g)/AP<>/D<>>>/TU(Check here if no medications are routinely taken)>> endobj 569 0 obj <>/T(If additional space is needed please list on a separate sheet and attach)/Subtype/Widget/Rect[256.08 537.96 264.96 544.44]/FT/Btn/P 4 0 R/AS/Off/DA(/Helv 0 Tf 0 g )/AP<>/D<>>>/TU(If additional space is needed, please list on a separate sheet and attach)>> endobj 573 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(MedicationRow1)/Subtype/Widget/Rect[54.24 498.84 183.6 512.28]/FT/Tx/P 4 0 R/Q 1/TU(Medication_Row_1)>> endobj 575 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(DoseRow1)/Subtype/Widget/Rect[184.92 498.84 226.56 512.28]/FT/Tx/P 4 0 R/Q 1/TU(Dose_Row_1)>> endobj 577 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(FrequencyRow1)/Subtype/Widget/Rect[227.88 498.84 318.48 512.28]/FT/Tx/P 4 0 R/Q 1/TU(Frequency_Row_1)>> endobj 579 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(ReasonRow1)/Subtype/Widget/Rect[319.8 498.84 575.88 512.28]/FT/Tx/P 4 0 R/Q 1/TU(Reason_Row_1)>> endobj 581 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(MedicationRow2)/Subtype/Widget/Rect[54.6 482.76 183.48 497.76]/FT/Tx/P 4 0 R/Q 1/TU(Medication_Row_2)>> endobj 583 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(DoseRow2)/Subtype/Widget/Rect[185.04 482.76 226.44 497.76]/FT/Tx/P 4 0 R/Q 1/TU(Dose_Row_2)>> endobj 585 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(FrequencyRow2)/Subtype/Widget/Rect[228 482.76 318.36 497.76]/FT/Tx/P 4 0 R/Q 1/TU(Frequency_Row_2)>> endobj 587 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(ReasonRow2)/Subtype/Widget/Rect[319.92 482.76 575.52 497.76]/FT/Tx/P 4 0 R/Q 1/TU(Reason_Row_2)>> endobj 589 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(MedicationRow3)/Subtype/Widget/Rect[54.48 468.36 183.6 481.8]/FT/Tx/P 4 0 R/Q 1/TU(Medication_Row_3)>> endobj 591 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(DoseRow3)/Subtype/Widget/Rect[184.92 468.36 226.56 481.8]/FT/Tx/P 4 0 R/Q 1/TU(Dose_Row_3)>> endobj 593 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(FrequencyRow3)/Subtype/Widget/Rect[227.88 468.36 318.48 481.8]/FT/Tx/P 4 0 R/Q 1/TU(Frequency_Row_3)>> endobj 595 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(ReasonRow3)/Subtype/Widget/Rect[319.8 468.36 575.64 481.8]/FT/Tx/P 4 0 R/Q 1/TU(Reason_Row_3)>> endobj 597 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(MedicationRow4)/Subtype/Widget/Rect[54.48 453.96 183.6 467.4]/FT/Tx/P 4 0 R/Q 1/TU(Medication_Row_4)>> endobj 599 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(DoseRow4)/Subtype/Widget/Rect[184.92 453.96 226.56 467.4]/FT/Tx/P 4 0 R/Q 1/TU(Dose_Row_4)>> endobj 601 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(FrequencyRow4)/Subtype/Widget/Rect[227.88 453.96 318.48 467.4]/FT/Tx/P 4 0 R/Q 1/TU(Frequency_Row_4)>> endobj 603 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(ReasonRow4)/Subtype/Widget/Rect[319.8 453.96 575.64 467.4]/FT/Tx/P 4 0 R/Q 1/TU(Reason_Row_4)>> endobj 605 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(MedicationRow5)/Subtype/Widget/Rect[54.48 439.56 183.6 453]/FT/Tx/P 4 0 R/Q 1/TU(Medication_Row_5)>> endobj 607 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(DoseRow5)/Subtype/Widget/Rect[184.92 439.56 226.56 453]/FT/Tx/P 4 0 R/Q 1/TU(Dose_Row_5)>> endobj 609 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(FrequencyRow5)/Subtype/Widget/Rect[227.88 439.56 318.48 453]/FT/Tx/P 4 0 R/Q 1/TU(Frequency_Row_5)>> endobj 611 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(ReasonRow5)/Subtype/Widget/Rect[319.8 439.56 575.64 453]/FT/Tx/P 4 0 R/Q 1/TU(Reason_Row_5)>> endobj 613 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(MedicationRow6)/Subtype/Widget/Rect[54.48 424.8 183.6 438.6]/FT/Tx/P 4 0 R/Q 1/TU(Medication_Row_6)>> endobj 615 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(DoseRow6)/Subtype/Widget/Rect[184.92 424.8 226.56 438.6]/FT/Tx/P 4 0 R/Q 1/TU(Dose_Row_6)>> endobj 617 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(FrequencyRow6)/Subtype/Widget/Rect[227.88 424.8 318.48 438.6]/FT/Tx/P 4 0 R/Q 1/TU(Frequency_Row_6)>> endobj 619 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(ReasonRow6)/Subtype/Widget/Rect[319.8 424.8 575.64 438.6]/FT/Tx/P 4 0 R/Q 1/TU(Reason_Row_6)>> endobj 622 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[51.8398 409.223 64.9307 420.743]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 621 0 R/AS/Off/BS<>>> endobj 627 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[84.3052 409.223 95.8251 420.743]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 621 0 R/AS/Off/BS<>>> endobj 621 0 obj <> endobj 632 0 obj <>/TU(Non-prescription medication administration is authorized with these exceptions)>> endobj 634 0 obj <>/T(Signature4)/Subtype/Widget/Rect[53.3454 386.509 302.727 396.655]/FT/Sig/P 4 0 R/DA(/Helv 0 Tf 0 g )/AP<>>> endobj 635 0 obj <>/T(Signature5)/Subtype/Widget/Rect[309.927 386.182 558.327 396.982]/FT/Sig/P 4 0 R/DA(/Helv 0 Tf 0 g )/AP<>>> endobj 637 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[56.5525 258.94 73.3088 272.555]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 636 0 R/AS/Off/BS<>>> endobj 642 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[79.0688 258.94 94.2542 272.555]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 636 0 R/AS/Off/BS<>>> endobj 636 0 obj <> endobj 647 0 obj <>/T(Text6)/Subtype/Widget/Rect[98.1818 258.219 148.254 273.273]/FT/Tx/P 4 0 R/DA(/Helv 10 Tf 0 g)>> endobj 648 0 obj <>/TU(Tetanus)>> endobj 651 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[56.5525 243.231 72.7852 256.846]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 650 0 R/AS/Off/BS<>>> endobj 656 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[78.5452 243.231 94.2542 256.846]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 650 0 R/AS/Off/BS<>>> endobj 650 0 obj <> endobj 661 0 obj <>/T(Text7)/Subtype/Widget/Rect[98.1818 242.182 147.927 257.237]/FT/Tx/P 4 0 R/DA(/Helv 10 Tf 0 g)>> endobj 662 0 obj <>/TU(Pertussis)>> endobj 665 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[56.0289 226.475 72.2616 240.613]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 664 0 R/AS/Off/BS<>>> endobj 670 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[78.0215 226.475 94.7778 240.613]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 664 0 R/AS/Off/BS<>>> endobj 664 0 obj <> endobj 675 0 obj <>/T(Text8)/Subtype/Widget/Rect[98.1818 225.491 147.6 241.2]/FT/Tx/P 4 0 R/DA(/Helv 10 Tf 0 g)>> endobj 676 0 obj <>/TU(Diphtheria)>> endobj 679 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[56.0289 210.242 72.7852 224.38]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 678 0 R/AS/Off/BS<>>> endobj 684 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[78.5452 210.242 95.3015 224.904]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 678 0 R/AS/Off/BS<>>> endobj 678 0 obj <> endobj 689 0 obj <>/T(Text9)/Subtype/Widget/Rect[97.8545 209.782 147.6 224.837]/FT/Tx/P 4 0 R/DA(/Helv 10 Tf 0 g)>> endobj 690 0 obj <>/TU(Measles/mumps/rubella)>> endobj 693 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[56.0289 194.009 73.3088 208.671]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 692 0 R/AS/Off/BS<>>> endobj 698 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[78.5452 194.009 95.3015 208.671]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 692 0 R/AS/Off/BS<>>> endobj 692 0 obj <> endobj 703 0 obj <>/T(Text10)/Subtype/Widget/Rect[98.1818 192.764 147.6 209.128]/FT/Tx/P 4 0 R/DA(/Helv 10 Tf 0 g)>> endobj 704 0 obj <>/TU(Polio)>> endobj 707 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[56.0289 177.777 73.3088 192.438]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 706 0 R/AS/Off/BS<>>> endobj 712 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[79.0688 177.777 94.7778 191.915]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 706 0 R/AS/Off/BS<>>> endobj 706 0 obj <> endobj 717 0 obj <>/T(Text11)/Subtype/Widget/Rect[97.8545 177.055 147.6 192.437]/FT/Tx/P 4 0 R/DA(/Helv 10 Tf 0 g)>> endobj 718 0 obj <>/TU(Chicken Pox)>> endobj 721 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[56.0289 161.544 73.3088 175.682]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 720 0 R/AS/Off/BS<>>> endobj 726 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[78.0215 161.544 95.3015 175.682]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 720 0 R/AS/Off/BS<>>> endobj 720 0 obj <> endobj 731 0 obj <>/T(Text12)/Subtype/Widget/Rect[97.8545 160.691 147.6 176.728]/FT/Tx/P 4 0 R/DA(/Helv 10 Tf 0 g)>> endobj 732 0 obj <>/TU(Hepatitis A)>> endobj 735 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[56.0289 145.311 73.8325 159.45]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 734 0 R/AS/Off/BS<>>> endobj 740 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[78.0215 145.311 95.3015 159.45]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 734 0 R/AS/Off/BS<>>> endobj 734 0 obj <> endobj 745 0 obj <>/T(Text13)/Subtype/Widget/Rect[97.8545 144.655 147.6 160.037]/FT/Tx/P 4 0 R/DA(/Helv 10 Tf 0 g)>> endobj 746 0 obj <>/TU(Hepatitis B)>> endobj 749 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[56.0289 129.079 73.8325 143.74]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 748 0 R/AS/Off/BS<>>> endobj 754 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[78.0215 128.555 95.3015 143.74]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 748 0 R/AS/Off/BS<>>> endobj 748 0 obj <> endobj 759 0 obj <>/T(Text14)/Subtype/Widget/Rect[97.8545 128.291 147.927 144.0]/FT/Tx/P 4 0 R/DA(/Helv 10 Tf 0 g)>> endobj 760 0 obj <>/TU(Meningitis)>> endobj 763 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[56.0289 112.846 73.3088 127.508]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 762 0 R/AS/Off/BS<>>> endobj 768 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[78.0215 112.846 95.3015 126.984]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 762 0 R/AS/Off/BS<>>> endobj 762 0 obj <> endobj 773 0 obj <>/T(Text15)/Subtype/Widget/Rect[98.1818 112.255 147.6 127.31]/FT/Tx/P 4 0 R/DA(/Helv 10 Tf 0 g)>> endobj 774 0 obj <>/TU(Influenza)>> endobj 777 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[56.5525 96.6134 73.8325 111.275]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 776 0 R/AS/Off/BS<>>> endobj 782 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[78.0215 96.6134 94.7778 110.752]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 776 0 R/AS/Off/BS<>>> endobj 776 0 obj <> endobj 787 0 obj <>/T(Text16)/Subtype/Widget/Rect[98.509 95.564 148.254 111.6]/FT/Tx/P 4 0 R/DA(/Helv 10 Tf 0 g)>> endobj 788 0 obj <>/TU(Other \(i.e., HIB\))>> endobj 791 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[56.5525 80.9044 73.3088 95.0425]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 790 0 R/AS/Off/BS<>>> endobj 796 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[77.4979 80.3807 95.3015 95.0425]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 790 0 R/AS/Off/BS<>>> endobj 790 0 obj <> endobj 801 0 obj <>/T(Text17)/Subtype/Widget/Rect[98.1818 80.1823 147.927 95.2368]/FT/Tx/P 4 0 R/DA(/Helv 10 Tf 0 g)>> endobj 802 0 obj <>/TU(Exemption to immunizations \(form required\))>> endobj 804 0 obj <>/TU(medical history [1])>> endobj 806 0 obj <>/TU(medical history [2])>> endobj 808 0 obj <>/TU(medical history [3])>> endobj 810 0 obj <>/TU(medical history [4])>> endobj 812 0 obj <>/TU(Reviewed by)>> endobj 814 0 obj <>/TU(Date)>> endobj 817 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[467.606 141.122 479.126 152.642]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 816 0 R/AS/Off/BS<>>> endobj 822 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[513.162 141.122 524.682 152.642]/DA(/ZaDb 0 Tf 0 g)/P 4 0 R/Parent 816 0 R/AS/Off/BS<>>> endobj 816 0 obj <> endobj 827 0 obj <>/TU(Reason)>> endobj 829 0 obj <>/TU(Approved by)>> endobj 831 0 obj <>/TU(Date)>> endobj 833 0 obj <>/TU(Expedition/crew No)>> endobj 835 0 obj <>/TU(or staff position)>> endobj 838 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[165.992 576.263 183.272 589.353]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 837 0 R/AS/Off/BS<>>> endobj 843 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[186.938 575.739 205.788 589.877]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 837 0 R/AS/Off/BS<>>> endobj 837 0 obj <> endobj 848 0 obj <>/T(Text18)/Subtype/Widget/Rect[208.473 576.982 576.0 590.4]/FT/Tx/P 5 0 R/DA(/Helv 0 Tf 0 g )>> endobj 850 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[57.0762 534.896 74.8797 546.415]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 849 0 R/AS/Off/BS<>>> endobj 855 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[79.0688 534.896 96.8724 546.415]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 849 0 R/AS/Off/BS<>>> endobj 849 0 obj <> endobj 860 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(ExplainMedication)/Subtype/Widget/Rect[185.52 534.24 312.84 547.2]/FT/Tx/P 5 0 R/Q 1/TU(Explain_Medication)>> endobj 863 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[57.0762 520.757 74.8797 532.801]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 862 0 R/AS/Off/BS<>>> endobj 868 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[79.0688 520.757 96.8724 533.325]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 862 0 R/AS/Off/BS<>>> endobj 862 0 obj <> endobj 873 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(ExplainFood)/Subtype/Widget/Rect[185.52 519.48 312.72 533.28]/FT/Tx/P 5 0 R/Q 1/TU(Explain_Food)>> endobj 876 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[318.37 534.896 337.744 546.415]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 875 0 R/AS/Off/BS<>>> endobj 881 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[341.933 534.896 360.784 546.415]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 875 0 R/AS/Off/BS<>>> endobj 875 0 obj <> endobj 886 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(ExplainPlants_2)/Subtype/Widget/Rect[448.68 534.24 576 547.2]/FT/Tx/P 5 0 R/Q 1/TU(Explain_Plants)>> endobj 889 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[318.37 521.281 337.744 532.801]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 888 0 R/AS/Off/BS<>>> endobj 894 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[341.933 520.757 360.784 532.801]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 888 0 R/AS/Off/BS<>>> endobj 888 0 obj <> endobj 899 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(ExplainInsect bitesstings_2)/Subtype/Widget/Rect[448.68 519.48 575.88 533.28]/FT/Tx/P 5 0 R/Q 1/TU(Explain_Insect bites/stings)>> endobj 901 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(Height inchesRow1)/Subtype/Widget/Rect[54.36 477.84 157.8 491.28]/FT/Tx/P 5 0 R/Q 1/TU(Height \(inches\)_Row_1)>> endobj 903 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(Weight lbsRow1)/Subtype/Widget/Rect[159.12 477.84 262.2 491.28]/FT/Tx/P 5 0 R/Q 1/TU(Weight \(lbs.\)_Row_1)>> endobj 905 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(BMIRow1)/Subtype/Widget/Rect[263.52 477.84 366.6 491.28]/FT/Tx/P 5 0 R/Q 1/TU(BMI_Row_1)>> endobj 907 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(Blood PressureRow1)/Subtype/Widget/Rect[383.282 477.84 416.685 491.28]/FT/Tx/P 5 0 R/Q 1/TU(Blood Pressure_Row_1)>> endobj 909 0 obj <>/T(Blood PressureRow2)/Subtype/Widget/Rect[421.933 477.906 455.336 491.346]/FT/Tx/P 5 0 R/DA(/Helv 0 Tf 0 g)/Q 1/TU(Blood Pressure_Row_2)>> endobj 910 0 obj <>/F 4/DA(/Helv 0 Tf 0 g)/T(PulseRow1)/Subtype/Widget/Rect[472.32 477.84 575.88 491.28]/FT/Tx/P 5 0 R/Q 1/TU(Pulse_Row_1)>> endobj 913 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[120.436 425.783 138.436 443.783]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 912 0 R/AS/Off/BS<>>> endobj 918 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[157.614 425.783 175.614 443.783]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 912 0 R/AS/Off/BS<>>> endobj 912 0 obj <> endobj 923 0 obj <>/T(Text19)/Subtype/Widget/Rect[187.527 422.837 294.545 446.727]/FT/Tx/P 5 0 R/DA(/Helv 0 Tf 0 g )>> endobj 925 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[120.436 401.696 138.436 419.696]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 924 0 R/AS/Off/BS<>>> endobj 930 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[157.614 401.172 175.614 419.172]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 924 0 R/AS/Off/BS<>>> endobj 924 0 obj <> endobj 935 0 obj <>/T(Text20)/Subtype/Widget/Rect[187.2 398.618 294.873 421.855]/FT/Tx/P 5 0 R/DA(/Helv 0 Tf 0 g )>> endobj 937 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[120.436 377.085 138.436 395.085]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 936 0 R/AS/Off/BS<>>> endobj 942 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[157.614 376.561 175.614 394.561]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 936 0 R/AS/Off/BS<>>> endobj 936 0 obj <> endobj 947 0 obj <>/T(Text21)/Subtype/Widget/Rect[186.873 374.728 294.873 397.637]/FT/Tx/P 5 0 R/DA(/Helv 0 Tf 0 g )>> endobj 949 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[121.483 352.474 139.483 370.474]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 948 0 R/AS/Off/BS<>>> endobj 954 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[158.138 352.474 176.138 370.474]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 948 0 R/AS/Off/BS<>>> endobj 948 0 obj <> endobj 959 0 obj <>/T(Text22)/Subtype/Widget/Rect[186.873 349.528 294.873 373.418]/FT/Tx/P 5 0 R/DA(/Helv 0 Tf 0 g )>> endobj 961 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[121.483 328.387 139.483 346.387]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 960 0 R/AS/Off/BS<>>> endobj 966 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[157.614 327.863 175.614 345.863]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 960 0 R/AS/Off/BS<>>> endobj 960 0 obj <> endobj 971 0 obj <>/T(Text23)/Subtype/Widget/Rect[186.545 325.637 294.545 348.873]/FT/Tx/P 5 0 R/DA(/Helv 0 Tf 0 g )>> endobj 973 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[121.483 303.776 139.483 321.776]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 972 0 R/AS/Off/BS<>>> endobj 978 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[158.138 303.776 176.138 321.776]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 972 0 R/AS/Off/BS<>>> endobj 972 0 obj <> endobj 983 0 obj <>/T(Text24)/Subtype/Widget/Rect[186.873 301.091 294.873 324.655]/FT/Tx/P 5 0 R/DA(/Helv 0 Tf 0 g )>> endobj 985 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[121.483 279.689 139.483 297.689]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 984 0 R/AS/Off/BS<>>> endobj 990 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[158.138 279.689 176.138 297.689]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 984 0 R/AS/Off/BS<>>> endobj 984 0 obj <> endobj 995 0 obj <>/T(Text25)/Subtype/Widget/Rect[187.2 277.2 294.873 300.109]/FT/Tx/P 5 0 R/DA(/Helv 0 Tf 0 g )>> endobj 997 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[121.483 255.602 139.483 273.602]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 996 0 R/AS/Off/BS<>>> endobj 1002 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[158.138 255.602 176.138 273.602]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 996 0 R/AS/Off/BS<>>> endobj 996 0 obj <> endobj 1007 0 obj <>/T(Text26)/Subtype/Widget/Rect[186.873 252.328 294.873 276.219]/FT/Tx/P 5 0 R/DA(/Helv 0 Tf 0 g )>> endobj 1009 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[121.483 230.991 139.483 248.991]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 1008 0 R/AS/Off/BS<>>> endobj 1014 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[157.614 230.991 175.614 248.991]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 1008 0 R/AS/Off/BS<>>> endobj 1008 0 obj <> endobj 1019 0 obj <>/T(Text27)/Subtype/Widget/Rect[187.2 227.782 294.545 251.673]/FT/Tx/P 5 0 R/DA(/Helv 0 Tf 0 g )>> endobj 1021 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[121.483 206.904 139.483 224.904]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 1020 0 R/AS/Off/BS<>>> endobj 1026 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[158.138 206.38 176.138 224.38]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 1020 0 R/AS/Off/BS<>>> endobj 1020 0 obj <> endobj 1031 0 obj <>/T(Text28)/Subtype/Widget/Rect[187.2 203.891 294.218 227.128]/FT/Tx/P 5 0 R/DA(/Helv 0 Tf 0 g )>> endobj 1033 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[307.373 398.227 323.082 409.747]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 1032 0 R/AS/Off/BS<>>> endobj 1038 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[333.984 398.227 350.741 409.747]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 1032 0 R/AS/Off/BS<>>> endobj 1032 0 obj <> endobj 1044 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[306.85 384.089 323.606 394.954]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 1043 0 R/AS/Off/BS<>>> endobj 1049 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[334.602 383.565 350.835 394.954]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 1043 0 R/AS/Off/BS<>>> endobj 1043 0 obj <> endobj 1055 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[306.85 362.554 325.701 374.663]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 1054 0 R/AS/Off/BS<>>> endobj 1060 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[334.602 363.405 351.359 375.187]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 1054 0 R/AS/Off/BS<>>> endobj 1054 0 obj <> endobj 1066 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[307.897 341.478 325.701 352.671]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 1065 0 R/AS/Off/BS<>>> endobj 1071 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[334.079 341.805 352.406 353.194]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 1065 0 R/AS/Off/BS<>>> endobj 1065 0 obj <> endobj 1077 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[307.897 327.013 325.701 338.533]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 1076 0 R/AS/Off/BS<>>> endobj 1082 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[333.555 327.013 352.406 338.533]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 1076 0 R/AS/Off/BS<>>> endobj 1076 0 obj <> endobj 1088 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[307.373 313.333 325.701 323.871]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 1087 0 R/AS/Off/BS<>>> endobj 1093 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[334.602 313.333 351.882 323.871]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 1087 0 R/AS/Off/BS<>>> endobj 1087 0 obj <> endobj 1099 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[307.897 298.736 325.701 309.209]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 1098 0 R/AS/Off/BS<>>> endobj 1104 0 obj <>/D<>>>/F 4/MK<>/Subtype/Widget/Rect[334.079 297.689 351.882 309.209]/DA(/ZaDb 0 Tf 0 g)/P 5 0 R/Parent 1098 0 R/AS/Off/BS<>>> endobj 1098 0 obj <> endobj 1109 0 obj <>/T(Signature3)/Subtype/Widget/Rect[363.49 275.783 499.635 290.619]/FT/Sig/P 5 0 R/DA(/Helv 0 Tf 0 g )/AP<>>> endobj 1110 0 obj <>/TU(Date)>> endobj 1112 0 obj <>/TU(Examiners printed name)>> endobj 1114 0 obj <>/TU(Address)>> endobj 1116 0 obj <>/TU(City)>> endobj 1118 0 obj <>/TU(State)>> endobj 1120 0 obj <>/TU(ZIP code)>> endobj 1122 0 obj <>/TU(Office phone)>> endobj 1124 0 obj <>/F<>>>/Rect[450.98 94.74 532.72 106.71]/DV()/BS<>/Subtype/Widget/FT/Tx/Q 1/P 6 0 R/DA(/TimesNewRomanPSMT 9 Tf 0 0 0 rg )/F 4/AP<>/MK<>/Ff 0/T(Text1)>> endobj 1126 0 obj <>/Subtype/Widget/FT/Tx/P 6 0 R/DA(/TimesNewRomanPSMT 12 Tf 0 0 0 rg )/F 4/AP<>/MK<>/Ff 0/T(Text2)>> endobj 1 0 obj <>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Group<>>> endobj 1129 0 obj <>stream xYnF},$C$/q5"q^P-%'Ld&,g;w=wH7xt~LXO#a_ao &_ɲN7Ln$2T,0}IgW]< Jke<2$aY dM&w;' gsZ 5JEv%!'!%S=M)JVĨ2D$(y,ajFjo\Q jo|]D{U@ o |H"2!ėIo8ߐxO94+сBD+RJ Пx`S sz]d Tz̊ίQ- h|+|4xG.OF^]~/&]{8: C/CF~{Kͨ?4T ~]T/D85I=&PDMz^{@AitnFF(¶B@UELP(?)>=Fd`/K'O:7-1Hɑ~#3*h&,s(P3eƫfgnԚACKE~unjՀ14Ɯ`0Rz]R'(L3pQϗ7+0]Ęղ=ᄑTÅ{kߧW?KCu? `hM8,vC|n"+Wv`|qKC/IƉoX0vOv +v&_UpbuJ`^?/v xp:Ch7ߙ`+PQU9SsY0v} /7k_/fqλ\HS/РsP9q;϶SmS8*8Snݪ,\4nkĮ5!U=wx/ 6 7ytX{3gV%+,6w$<# GY}?|CY&|lvOD* +,&dfe]a@O 9g7M;҉~vw\T,+OKarڤckTg4IohX\8m51RPT"e ֑HW)P) ܹߜ7OP0,rfm|f^E"A偐_T9Qtz#qHQ9h2|;Vf>o AfԵtUSj+B{p]}cj6$4hW5SMr<{u͑YPڷ5\̓x>Æ&y]h*_fiC:Ɩu뇜/E]wX$eQGi͘ ?Qvo?k'I꣬S<4nR LqC-SMA'=Nno sug~ֵ F`s4NgȪܻj<&H+Ǽx@ -8" }g?/(Ln+]Kwp([ ,Z3Y$i%pjRgld0x،r[%7YjUT ݙ~@g EgAFlB$|"^O.emQ(e2B謅]cfY6w玳JvLp[Ħ^Ԏ^+ºA5,8ەY!~V4U5(RCl| ՞Ld?_%îp'(oxE%\7fC5So>6Ad@Di0l%,^Jh endstream endobj 1141 0 obj <> endobj 1143 0 obj <> endobj 1131 0 obj <> endobj 1130 0 obj <> endobj 1138 0 obj <> endobj 1140 0 obj <> endobj 1135 0 obj <> endobj 1137 0 obj <> endobj 1132 0 obj <> endobj 1134 0 obj <> endobj 1145 0 obj <> endobj 1146 0 obj [1147 0 R] endobj 1147 0 obj <> endobj 1149 0 obj <> endobj 1150 0 obj <> endobj 1154 0 obj <>stream JFIF C $.' ",#(7),01444'9=82<.342 C 2!!22222222222222222222222222222222222222222222222222 [" } !1AQa"q2#BR$3br %&'()*456789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz w !1AQaq"2B #3Rbr $4%&'()*56789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz ? ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( (_:hZ#Hk>F};]-$^-≙CSkf{F]. P[ Y[jq_%40s-GÐLc88 %c@WR#G̪0]u QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE QE