ALLERGY & MEDICAL PROFILE FORM

ALLERGY & MEDICAL PROFILE FORM
The information contained in this form is confidential and will only be shared with the
trip leaders/guides and medical personnel in the case of an emergency.
Participants Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Tour Name & Location
Doctor Name
Doctor Phone Number
Please enter a valid phone number.
Are you allergic to any medication, food, bites, etc.
If yes, what is the severity of the allergy?
What should be done in case of a reaction?
Please list any dietary restrictions we should be aware of:
vegan, gluten intolerance, lactose intolerance, allergies
Do you suffer from any pre-existing medication conditions? (for example diabetes,epilepsy, heart condition, etc.)
What should be done in case of an emergency?
Are you taking any prescription or non-prescription drugs? If yes, give details
Name of Emergency Contact #1

First NameLast Name
Relationship
Phone Number of Emergency Contact #1
Please enter a valid phone number.
Address of Emergency Contact #1

Civic Address

CityState / Province

Postal / Zip CodeCountry
Name of Emergency Contact #2

First NameLast Name
Relationship
Phone Number of Emergency Contact #2
Please enter a valid phone number.
Address of Emergency Contact #2

Civic Address

CityState / Province
All of the information is accurate as of today’s date. If there are changes, I agree to
contact LAO with updated information.
Date

MonthDayYear
Date
Signature*

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Should be Empty: