Participant Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Person
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about us?
Intake Questions
Do you have any medical conditions or concerns that we should know about (ex. low vision, balance concerns, cognitive challenges)?
*
Are you currently taking any medications we should be aware of that you may need in a medical emergency on our trip? If yes, please list below.
*
Do you experience motion sickness while traveling in a vehicle?
Yes
No
Do you have any allergies? If yes, please list them below.
*
Do you use mobility equipment?
*
Wheelchair
Walker
Cane
Motorized Wheelchair
None
Other
Do you require a personal aid or caregiver to use the bathroom, for transfers, or while using mobility equipment? If so, explain.
Have you been hospitalized in the last 30 days?
*
Yes
No
If you have been hospitalized in the last 30 days, please explain.
Are you currently taking blood thinners?
Yes
No
Do you use supplemental oxygen? If so, how long does your portable tank or battery last?
Do you have any dietary restrictions or food allergies?
Is there anything else you think we need to know before our trip?
Acknowledgment
Check all that apply:
*
I understand Blue Ridge Elder Adventures LLC reserves the right to refuse or discontinue any service at any time based on the medical professional or staff's discretion.
I certify that all information in this form is accurate and true to the best of my knowledge.
I agree to bring my medication that may be required during a medical emergency based on my medical history. (ex. asthma inhaler, EpiPen, etc.)
I grant permission to Blue Ridge Elder Adventures, LLC to take photographs or videos for the purpose of advertising and marketing.
*
Yes
No
Your Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: