Please complete this form and return it to your leader within 30 days.
Please fill in this form as accurately as possible, it is essential for Leaders to evaluate individual and group health needs
as part of trip planning, and for use during emergencies. The information will remain confidential, and then be destroyed.
Your Leader may follow-up by phone or email.
General Information Trip Number
Name: Age: Date of Birth
Height Weight: Gender: Blood Pressure / Resting Heart Rate: bpm
Address: Email:
City: State: Zip:
Mobile Phone: Home Phone:
Primary Emergency Contact: Relationship:
Home:( ) Work:( ) Mobile: ( )
Secondary Emergency Contact: Relationship:
Home:( ) Work:( ) Mobile: ( )
Evacuation and Medical Insurance
We strongly encourage you to have medical and evacuation insurance and to bring your insurance card or other
documentation with you on the trip
Evacuation Insurance
Medical Insurance
Company Name:
Policy Number:
Contact Phone Number:
Coverage Amount:
Company Name:
Policy Number:
Contact Phone Number:
Include allergies to food, insect bites and stings, medicines, animals and environment (dust, pollen, etc.)
Select NO ALLERGIES if none.
Medication Required
Please list all prescription, over the counter, and natural medications you are currently taking. Note if this
is a recent change in dosage or prescription. Use separate sheet if needed.
Side Effects (known and
Reason for
Medical Form
General Medical History
Please answer the following medical history questions. If answering YES, use a separate sheet to explain history in
more detail.
Do you currently have, or have a history with, the following conditions:
Respiratory problems, Asthma, Do you smoke YES
Diabetes YES NO
Gastrointestinal problems YES NO
Cardiac problems, Hypertension YES NO
Neurological problems, Seizures YES NO
Vision or Eye problems YES NO
Hearing problems YES NO
Bone, Joint, Muscle Problems YES NO
Head trauma , Traumatic Brain Injury YES NO
stance Abuse, Anxiety, Depression YES
If female, are you pregnant YES NO
Have you had a recent illness within the last 12 months YES NO
Have you had surgery or been hospitalized in the last year YES NO
Have you ever had problems related to exposure with altitude YES NO
Any other Health complaint or medical issue that would affect your participation on this trip YES NO
If yes, Please explain .
Date of last tetanus immunization: Please describe your swimming ability:
Date of most recent physical: Physician’s name:
Address: Phone:
Please have physician sign if required by your Leader to obtain a physical prior to trip
Physician’s signature: Date
The information provided here is a complete and accurate statement of any physical and psychological
conditions that may affect my participation on this trip. I realize that failure to disclose such information
could result in serious harm to myself and other participants. I agree to inform my trip leader should there
be any changes to my health status prior to the start of the trip. I understand the outing may require
vigorous activity that is both physically and mentally demanding in isolated areas without medical
facilities. I am fully capable of participating on this trip.
Trip Name Trip Dates
Participant Signature Date