MEDICAL & GENERAL INFORMATION FORM Print Version MEDICAL and GENERAL INFORMATION FORM Your Information Name * First Last Last Phone * Email * Date of Birth Gender Male Female Other Primary Care Physician Phone Emergency Contact Info Name * First Last Last Phone Relationship For sizing boats, paddles, life jackets, and other equipment I need to know your: Height Weight Shoe Size Shirt Size SmallMediumLargeXtra Large MEDICAL INFORMATION: Please list any important conditions like allergies (especially foods), asthma, diabetes, heart conditions, joint replacements, pregnancy, etc: MEDICATIONS you take that I should know about (continue on back if needed): Do you have MEDICAL INSURANCE? (Medical expenses are your responsibility) Yes No Medical Insurance Company GENERAL INFORMATION Tell me a bit about your outdoors experiences, capabilities and comfort levels with swimming , kayaking, hiking, camping etc: What most interests you for this outdoor learning adventure? Check some favorites like: Relaxation Challenges Learning About Nature Getting Outdoor Experience Biology Regional History Photography or describe your interests in your own words: Confirmation * I confirm that the information I've provided is to the best of my knowledge. Once you SUBMIT you will have the opportunity submit additional forms. If you are human, leave this field blank. Submit
