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?

Do you have any type of allergy?

Explain

Dietary Restrictions

Check here to confirm you have read and agree to the terms and conditions outlined in the trip release waiver form.

Are you covered by medical insurance in the USA

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

Have you purchased insurance for this trip that includes additional foreign or domestic medical coverage.

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.

In the event of an emergency do you give us your permission to do what is necessary to get you treatment?

Do you understand that all financial responsibility for treatment or evacuation will be yours?

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)?

Do you give us permission in the event needed to provide you with over the counter medication?

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.

Will my items will be packed in an adventure style backpack?

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.