Medical Information Form

The medical information you provide helps us to minimize risk and make your trip as safe as possible. Please fill this form out as completely and accurately as you can.

Full name

Date of birth

Month

Day

Year

Phone (the number that you can be reached on during the trip)

Email

Person to contact in case of emergency

Name of emergency contact

Phone of emergency contact

Is this person traveling with you?

Yes

No

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 homeopathic supplements that we should know about? (list all medications and dosage)

Do you have any allergies including foods, animals, insects, or medications? (please explain the allergen, the reaction, and the treatment required)

If you do have allergies, do you carry your own personal anaphylaxis kit?

Do you have any physical or mental limitations on your activities, or any other condition that could affect your health or performance during physical activity?

Please check the box if you have had any of the following conditions:

Please provide more information for any of the checked boxes above.

By checking this box and submitting this form, you agree that the above information is complete, true, and accurate to the best of your knowledge.

SMART GUIDES

Medical Information Form

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Medical Information Form

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