The purpose of this medical questionnaire is to find out if you should be examined by your doctor before participating in the CRI/Counter Terrorism Training School _____________________________________________________ course.

The fact that there may be a preexisting medical condition that may affect your safety while training requires your attention to seek the advice of your physician. Please complete the form and contact CRI at the number or e-mail address below.

Student Name (please print legibly): _______________________________________________________________________

Street Address:  ______________________________________________________________________________________

City: _________________________________  State: ___________  Zip: _________________________________________

Tel: __________________  Fax: __________________  Email: __________________________________________________

For Physician:

This person is an applicant for a firearm training course that requires strenuous physical activities and high stress threat scenarios.

The applicant reports a past medical history of:
1. _________________________________________________________________________________________________
2. _________________________________________________________________________________________________
3. _________________________________________________________________________________________________

Physicians Impression: (please check one)

__ I find no medical condition that I consider incompatible with said training.
__ I am unable to recommend this individual for said training.

Remarks: ____________________________________________________________________________________________

Physician signature: ____________________________________________ ,M.D.  Date ______________________________

Clinic/Hospital Name: __________________________________________________________________________________

Clinic/Hospital Address: ________________________________________________________________________________

Tel: _________________ Fax: ____________________ Email: __________________________________________________

 CRI -TRAINING REGISTRATION FORM

                                  (Please fax or mail this form to CRI’S office PRIOR to the course date).

                         Please check one:  □  Law Enforcement       □     Federal            □   Military            □   Civilian                                        

  CRI reserves the right to refuse training to any individual, group or other entity.                    

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