VITAL Health & Lifestyle Form

**Privacy & Confidentiality**

All personal and medical information collected on this form will be kept confidential and only shared with VITAL Ventures staff or emergency personnel if necessary to ensure your safety and wellbeing during your participation in VITAL activities. This form is used solely to support safe and informed participation in adventure experiences.

Full Name:

Date of Birth:

Date

Age:

Gender:

Height:

Weight:

Phone Number:

Format: (000) 000-0000.

Email Address:

example@example.com

Mailing Address:

Emergency Contact Name:

Relationship:

Phone Number

Format: (000) 000-0000.

1. General Health

How would you describe your present state of health?

Do you have any medical conditions that might affect your participation?

If Yes please specify:

Have you been hospitalized or required medical care in the last 5 years?

If Yes please provide details:

Are you currently under a physician's care for any medical condition?

2. Medical Conditions

Check all that apply:

If not listed, please list all below:

3. Medications & Allergies

Do you take any medications that would be important for us to be aware of in the event of an emergency?

If Yes list all medications dosage and frequency:

Do you have any allergies?

If Yes specify allergens (medications foods insects environmental etc.) and severity:

Do you have a prescription for, and carry, an EPI Pen?

4. Surgical & Injury History

Have you had any major surgeries that may impact your ability to participate?

If Yes describe:

Have you had any past injuries that may affect your activity level?

If Yes describe:

5. Physical Fitness & Activity Level

Do you engage in regular physical activity?

If Yes describe type & frequency:

What is your primary fitness goal for this trip?

6. Dietary & Nutrition Information

Do you follow any specific diet?

If other please specify:

Do you have any hydration concerns (e.g., history of dehydration, kidney issues)?

If Yes please describe:

7. Insurance & Emergency Care Information

This information is optional and will only be used in an emergency (e.g., evacuation support). This information is securely stored and only accessed if and when needed. If you do not want to disclose, please carry a physical copy on you during the entire event and provide a copy to your emergency contact.

1. Medical Insurance Provider:

Policy Number:

Insurance Contact Phone Number:

2. Primary Care Physician Name:

Contact Phone Number:

3. Do you have medical evacuation insurance?

If Yes, Company Name:

Phone Number:

4. Authorization for Emergency Medical Care

In the event of an emergency, I authorize VITAL Ventures and medical personnel to provide necessary care.

Participant Signature:

Date:

Date

Physician’s Release Requirement

If you answered "Yes" to any of the questions regarding medical conditions, surgeries, or physical concerns, you are required to provide a signed physician’s release to ensure your participation in the upcoming adventure.

Please have your physician review your health information and confirm that you are cleared for physical activity related to this program. This signed release is required for all individuals who answer "Yes" to any medical-related question.

Assumption of Risk & Liability Waiver

I understand that adventure travel involves risks, including but not limited to injuries, altitude sickness, and exposure to unpredictable environmental conditions.

I certify that all information provided is accurate and complete.

I accept full responsibility for my health and participation.

I agree to the terms and conditions outlined in this assessment.

Signature

Date

VITAL Health & Lifestyle Form

Medical Information & History