Get Appendix Five

Filling out the Appendix Five form is a crucial step in ensuring your participation in the program at Eastern Washington University. This guide provides clear and supportive instructions to help you provide the necessary medical information accurately.

Follow the steps to successfully complete the Appendix Five form.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out Part I, General Information. This section requires your name, gender, height, weight, date of birth, daytime and evening phone numbers, fax number, email address, and residential address. Indicate whether you speak and understand English.
3. Provide information for your parent or guardian if applicable, including their name and contact details.
4. List an emergency contact other than your parent or guardian. Include their name and multiple phone numbers for daytime and evening.
5. Fill out your family physician's name and contact information in the designated fields.
6. Complete the insurance information section, supplying your insurance company name, policy number, prescription plan number, and telephone number. Remember to attach a photocopy of both sides of your insurance card.
7. Proceed to Part II, Medical Information. Here, indicate if you have any allergies, current medications you're taking, and any relevant medical history. Be specific about allergies, reactions, and medications.
8. Move on to Part III, Health Profile. Respond to the health questions regarding any recent seizures, hospitalizations, or other medical conditions. If needed, attach additional documentation.
9. Review and authorize the release of your medical information, which includes consent for emergency treatment necessary for your safety.
10. Finally, sign and date the form to confirm the information provided is accurate. After completing all sections, ensure to save any changes made, and you can download, print, or share the completed form as needed.

Complete your Appendix Five form online today to ensure your place in the program.