Medical Information Form

Please fill out the following form
in order to participate in our activity.

First name

Last name

Date of Birth

Phone (for contact during the trip)

Person to contact in case of emergency

Phone

Do you have any physical or mental limitations on your activities 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 itamins, and/or homeopathic 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 info I’ve provided is accurate & complete

Initials

Thanks for submitting!