Trip Information Form

Trip 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 prior to your trip. All information is kept confidential.
Full Name*

First NameLast Name
Pronoun
Trip Name*
Trip Date*

MonthDayYear
Date
Birth Date*

MonthDayYear
Date
Phone Number*
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.
Check the conditions that apply to you:

AsthmaCancerCardiac diseaseDiabetesHypertensionPsychiatric disorderEpilepsyOther
Please list any other conditions which may limit your endurance, strength or agility:

Limited range of motionKnee issuesTendon/ ligament damageJoint replacementTraumatic Brain InjuryRecent SurgeryAwaiting SurgeryVertigoOther
Are you currently taking any medication?*

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.
Do you have any allergies?*

YesNoNot Sure
If yes, please list:
What is your Gender?

MaleFemale
Are you currently Pregnant?*

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.
Activity Options/ Expectations
What are your areas of interest for this trip?

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
Should be Empty:

Trip Information Form

Physical Conditioning

Medical Information

Activity Options/ Expectations