Trip Booking & Information Form

Trip Booking & Information Form
White Mountain Adventures looks forward to welcoming you soon on your exciting trip with us. In order to make your adventure the best that it can possibly be we require some specific information from you. Please complete this form to initiate your booking. All information is kept confidential.
Full Name*

First NameLast Name
Trip Name*
Trip Date*

MonthDayYear
Date
Birth Date*

MonthDayYear
Date
Phone Number*
Format: (000) 000-0000.
Physical Conditioning
How much walking do you do in a week?*
On what type of terrain do you generally walk?*
How would you rate your physical conditioning (for your age)?*
Medical Information

The information collected in this form aids our staff when responding to any emergencies that may arise and will not result in your exclusion from any of our programs.
AsthmaCancerCardiac diseaseDiabetesHypertensionPsychiatric disorderEpilepsyOther
Limited range of motionKnee issuesTendon/ ligament damageJoint replacementTraumatic Brain InjuryRecent SurgeryAwaiting SurgeryVertigoOther
YesNo
If yes, please list: *
* Please note, for all critical medications we require you to bring a double dose on your trip. You will carry one and your trip leader will carry one as a backup.
YesNoNot Sure
If yes, please list:
MaleFemale
YesNo
If yes, how many months:
Do you have any dietary restrictions? If yes, please list:
In case of emergency, who should we contact?*

First NameLast Name
Emergency contact phone:*
Please enter a valid phone number.Format: (000) 000-0000.
Activity Options/ Expectations
Local FloraLocal FaunaWildlife HabitatsHistoryGeologyOther
What experiences would make this trip enjoyable/ worthwhile for you?
What do you hope to learn more about on this trip?
Thank you for taking the time to complete this form. We look forward to not only meeting, but exceeding your expectations. Please contact our office if you have any questions related to the completion of this form. 1-800-408-0005 or info@whitemountainadventures.com
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Trip Booking & Information Form

Physical Conditioning

Medical Information

Activity Options/ Expectations