Teen Backpack Medical/Emergency Form

Teen Backpack Medical/Emergency Form

To be filled in by Parent/Guardian
Teen Hiker Name*

First NameLast Name
Parent/Guardian Email*
example@example.com
Emergency Contact Information

Primary Contact
Emergency Contact 1*

First NameLast Name
Mobile Phone*
Best Other Phone
Other Phone Location
Work, Landline at home, etc
Relationship to Teen*
Mother, Aunt, Grandfather, etc.
Backup Contact
Emergency Contact 2*

First NameLast Name
Mobile Phone*
Best Other Phone
Other Phone Location
Work, Landline at home, etc
Relationship to Teen*
Mother, Aunt, Grandfather, etc.
Medical Information

We want all hikers to have the best experience possible. To care for both your hiker and the rest of the group, please answer the following questions honestly. This is information is confidential and will not be shared outside of Wild Grief.
Medical Insurance Carrier and Contact Number if possible
Height
Weight in Pounds
Good nutrition on the trail is important to the trip's success. Hikers will be active and need to eat. We will provide all food and want to accommodate dietary restrictions and concerns to the extent possible. Does the hiker 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 the hiker may have around food or eating.*
Does the hiker 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.
Does the hiker take any medications?*

YesNo
If the hiker is taking medications, please describe each medication. Press the "+" to add more rows. You can resize the boxes.
Does the hiker 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, treatment, and dates. Also, if you know of some other medical condition not listed that could impair the hiker's well-being on a backpack trip, please specify below:
What is the hiker's current level of physical activity?*

Very ActiveActiveOccasionalRare physical activity
Please describe activity level above in the last six months (e.g. Walks 2x a week, runs every day, hikes once a month)*
Does the hiker have any known physical, mental or social difficulties which may affect participation on this hike?*

YesNo
If yes above, please explain and describe.*
Does the hiker have a recent history of attempted suicide or non-suicidal self-injury including cutting, reckless driving, or other disregard for their own safety? If yes, please describe.*

YesNo
If yes above, please explain and describe.*
Is there anything you would like us to know about this hiker?.*
Thank you for applying to join us on the trail. We will review your application get back to you to schedule an interview/orientation soon.
Signature*
Should be Empty:

Teen Backpack Medical/Emergency Form

Emergency Contact Information

Medical Information