Dietary and Medical Information

In order to further ensure the health and safety of every CLI program participant, it is important that we collect the following information, which we will have access to throughout your upcoming program. Please note that this information is confidential and will only be accessible by CLI team members directly associated with your upcoming program and by your program's faculty leader. Only fields with an asterisk (*) are required.
Basic Information
(Enter the email addresses that you used in your CLI Student Information Form. A copy of your Student Info Form responses was emailed to you upon initial completion.)
 
Dietary Information
(if none, enter NA)
(if none, enter NA)
Please use the below space to provide any additional information about your dietary needs and preferences that you think might be helpful to your program organizers.
 
Medical Information
(if none, enter NA)
(if none, enter NA)
(if none, enter NA)
(enter NA if necessary)
(enter NA if necessary)
(enter NA if necessary)
Please use the below space to provide any additional information that you think might be helpful to your program organizers.
 
Please answer Yes/No to the following. In the past 3 years, have you experienced:
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
 
The above information is accurate and correct to the best of my knowledge.