Young Adult Backpack Medical/Emergency Form

Young Adult Backpack Medical/Emergency Form
Your Name*

First NameLast Name
Your Email
example@example.com
Emergency Contact Information

Primary Contact
Emergency Contact 1*

First NameLast Name
Mobile Phone*

Area CodePhone Number
Best Other Phone

Area CodePhone Number
Other Phone Location
Work, Landline at home, etc
Relationship to you*
Mother, Aunt, Grandfather, etc.
Backup Contact
Emergency Contact 2*

First NameLast Name
Mobile Phone*

Area CodePhone Number
Best Other Phone

Area CodePhone Number
Other Phone Location
Work, Landline at home, etc
Relationship to you*
Mother, Aunt, Friend, Grandfather, etc.
Medical Information

We want all hikers to have the best experience possible. To care for both you and the rest of the group, please answer the following questions honestly. This is information is confidential.
Medical Insurance Carrier and Contact Number if possible
Good nutrition on the trail is important to the trip's success. You will be active and need to eat. We will provide all food and want to accommodate dietary restrictions and concerns to the extent possible. Do you have any dietary restrictions (Vegetarian, Vegan, Food Allergies, etc)*

YesNo
If you answered yes above, please explain more about dietary restrictions or food allergies here:
Please describe any other concerns or issues you may have around food or eating.*
Do you have any allergens besides food listed above (include medicines, bites, stings, hay fever, etc?*

YesNo
If yes above, please describe each allergen. Press the "+" to add more rows. You can resize the boxes.
Do you take any medications?*

YesNo
If you are taking medications, please describe each medication. Press the "+" to add more rows. You can resize the boxes.
Do you have any of the following:*

Seizure/epilepsyDiabetesBack problemsAsthmaHeart defect/ diseaseHypertensionRespiratory diseaseShortness of breathHearing ImpairmentNosebleedsAllergiesPsychological problemsKnee/ankleHerniaSprains/jointsRecent surgerySleep ProblemsHospitalization/ER visit in last yearOther
If you checked any conditions above, please give a detailed description including symptoms, diagnosis if any, treatment, and dates. Also, if you know of some other medical condition not listed that could impair your well-being on a backpack trip, please specify below:
Height
Weight in Pounds
What is your current level of physical activity?*

Very ActiveActiveOccasionalRare physical activity
Please describe activity level above in the last 6 months (e.g. Walk 2x a week, run every day, hike once a month)*
Do you have any known physical, mental or social difficulties which may affect participation on this hike?*

YesNo
If yes above, please explain and describe.*
Do you have a recent history of attempted suicide or non-suicidal self-injury including cutting, reckless driving, or other behaviors that may be unsafe?*

YesNo
If yes above, please elaborate.*
Are there any other restrictions desired by you or your physician?.*
Is there anything else you would like us to know?*
Thank you for applying to join us on the trail. It can take some time for us to review applications. We will get back to you as soon as we are able. In the meantime, feel free to reach out to us with any question.

Email: info@wildgrief.org

Call/Text: 360-358-3213
Signature*
Should be Empty:

Young Adult Backpack Medical/Emergency Form

Emergency Contact Information

Medical Information