Medical Information Form

Please provide accurate information so we can be prepared for any situation during your trip.

First name

Last name

Phone

Preferrably one that you can be reached on during the trip

Date of Birth

Month

Day

Year

Person to contact in case of emergency

Phone of emergency contact

Do you have any physical or mental limitations including injuries or illnesses or any other condition that could affect your health or performance during physical activity?

Are you currently or will you be taking during the trip any medications or drugs including prescription medications, over-the-counter drugs, vitamins, and/or supplements that we should know about? (list all medications and dosage)

Do you have any allergies? If so, do you carry your own personal anaphylaxis kit? Please explain the allergen, the reaction, and the treatment required.

I declare that the information I've provided is accurate and complete.

Signature

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