REQUIRED MEDICAL FORM

Name*

FirstLast

E-mail*

Contact Number*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact*

First NameLast Name

Contact Number*

Area CodePhone Number

Relationship to You?*

YesNo

Explain

Dietary Restrictions

AgreeDisagree

YESNO

BE ADVISED! YOU ARE REQUIRED TO BRING AN EPI-PEN IF A KNOWN ALLERGY COULD RESULT IN ANAPHYLAXIS.

YESNO

BE ADVISED! DOMESTIC MEDICAL INSURANCE MAY NOT COVER INCIDENTS OCCURRING INTERNATIONALLY. CHECK WITH YOUR PROVIDER. ADDITIONALLY, IT IS THE RECOMMENDATION THAT EACH PARTICIPANT PURCHASE TRIP INSURANCE THAT OFFERS ADDITIONAL MEDICAL COVERAGE & EVACUATION.

YESNO

Will you be bringing any medication with you?

BE ADVISED! RESEARCH AND ACQUISITION OF ALL REQUIRED VACCINATIONS IS YOUR RESPONSIBILITY. TRAVELERS ARRIVING AT CUSTOMS WITHOUT A VALID IMMUNIZATION RECORD (YELLOW BOOKLET) MAY BE DENIED ENTRY INTO DESTINATION COUNTRY.

Have you received or will you receive prior to travel the proper vaccinations required for entry into destination country(s)? *

YESNO

BE ADVISED!! WE RECOMMEND EACH PARTICIPANT TO BRING A SMALL FIRST AID KIT WITH ANY ITEMS THEY FEEL WOULD KEEP THEM COMFORTABLE IN THE EVENT OF A MINOR HEALTH ISSUE.

Do you have ANY history of ANY medical condition that we may need to know about?

Do you have ANY history of ANY mental or emotional issues that we may need to know about?

BE ADVISED!! WE REQUIRE ALL PARTICIPANTS TO HAVE THEIR GEAR PACKED IN A PROPER ADVENTURE STYLE BACKPACK. NO SUITCASES WILL BE ALLOWED. ONLY ONE BACKPACK AND ONE SMALL DAY PACK ARE ALLOWED. ALL ITEMS BROUGHT WITH YOU MUST FIT IN THOSE TWO BAGS AND YOU WILL NEED TO BE PREPARED TO CARRY BOTH FOR MULTIPLE HOURS AT TIMES. DO NOT BRING EXTRA ITEMS THAT YOU DO NOT WANT TO CARRY. IF MOUNTAIN CLIMBING… THIS IS EVENT MORE IMPORTANT OF A NOTICE.

YESNO

Rate your expected level of adventure*

	1	2	3	4	5	6	7	8	9	10

1 is LOW, 10 is RAMBO

Travel Experience*

Dislikes*

Anything we missed?*

BY CLICKING SUBMIT I VERIFY ALL THE INFORMATION PROVIDED IS TRUE AND CORRECT. I FURTHER VERITY I UNDERSTAND THE PSYCHICAL REQUIREMENTS NECESSARY TO PARTICIPATE IN THIS ADVENTURE AND I FEEL I AM ABLE TO DO SO WITHOUT RISKING MY OWN HEALTH OR THAT OF ANOTHER PARTICIPANT.