Atlantic Kayak Company Medical Information Form
In order to be prepared to handle medical emergencies, we ask that you please fill in all information requested. Thank you!
Trip Date(s): ______________ Trip Location:____________________ › Class › Tour
Name:
Home Phone: Cell :
Age Range: › 20s › 30s › 40s › 50s › 60 and over › Minor
How did you hear about us: ›Web ›Word of Mouth ›Yellow Pages ›Publication › Other
In case of emergency, notify: ____________________________________________
Relationship: Phones: ___________________________
(1) Please describe your skill level and fitness for:
Paddling: ________ Swimming: ___________
(2) Do you have any medical conditions or physical limitations that we should be aware of or that may affect your participation? (These might include diabetes, epilepsy, high blood pressure, heart disease, any significant back, leg, foot, arm, or hand problems.)
› No › Yes If yes, please explain: _______________________________________
(3) Do you have any allergies, including allergic reaction to any drugs, insects, foods, or anything else (if you have severe insect allergies, you must bring medication to treat yourself in the event of a sting).
› No › Yes If yes, please explain: _______________________________________
(4) I am currently taking the following medications: _______________________________________________________________________
I agree that the above information is accurate and complete to the best of my knowledge.
Signature: _______________________________ Date: _________________________
For participants under age 18 at time of registration:
__________________________________ Date: _____________________
Parent or Guardian’s Signature
__________________________________
(printed name)
Trip Date(s): ______________ Trip Location:____________________ › Class › Tour
Name:
Home Phone: Cell :
Age Range: › 20s › 30s › 40s › 50s › 60 and over › Minor
How did you hear about us: ›Web ›Word of Mouth ›Yellow Pages ›Publication › Other
In case of emergency, notify: ____________________________________________
Relationship: Phones: ___________________________
(1) Please describe your skill level and fitness for:
Paddling: ________ Swimming: ___________
(2) Do you have any medical conditions or physical limitations that we should be aware of or that may affect your participation? (These might include diabetes, epilepsy, high blood pressure, heart disease, any significant back, leg, foot, arm, or hand problems.)
› No › Yes If yes, please explain: _______________________________________
(3) Do you have any allergies, including allergic reaction to any drugs, insects, foods, or anything else (if you have severe insect allergies, you must bring medication to treat yourself in the event of a sting).
› No › Yes If yes, please explain: _______________________________________
(4) I am currently taking the following medications: _______________________________________________________________________
I agree that the above information is accurate and complete to the best of my knowledge.
Signature: _______________________________ Date: _________________________
For participants under age 18 at time of registration:
__________________________________ Date: _____________________
Parent or Guardian’s Signature
__________________________________
(printed name)