NameJohn Burnham
Date of Birth05/21/1956
Address88 Oliphant Lane
Middletown, RI 02842
United States
Map It
Mobile Phone(401) 835-2686
EmailEmail hidden; Javascript is required.
I am a competent swimmerYes
In Case of EmergencyPlease provide an Emergency Contact
NameRachel Balaban
Mobile Phone(401) 261-7062
EmailEmail hidden; Javascript is required.

She is my better half.

Health HistoryThe following information is requested. This information will be kept confidential and shared only when as deemed needed. Any changes to this information must be provided to the boat captain. Please provide complete information, so that we can be aware of your needs.
COVID-19 VaccineYes

None significant

Dietary Restrictions


Medications Being TakenYES, Medications as follows
Medications Taken

warfarin 7.5mg daily, etc.

Do you have a history of Asthma?No
Do you have a history of seizures?No
Are you Diabetic?No
Do you have abnormal blood pressure or a history of heart disease?Yes
Have you ever had an anaphylactic reaction?No
Blood Type if knownA-
If you answered Yes, please explain.


Food PreferencesPlease check those you like & add comments where necessary
Food Likes
  • Fish
Bar Preferences
  • Beer
  • Wine
  • Rum
Other Additional Information

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