PARTICIPANT INFORMATION
Completed and signed forms are mandatory prior to participation.
Participant Name (Last)
(First)
(Middle Init)
Birthdate
Sex (circle one)
M
Address (Street & Apartment No.)
City
Work Phone (
)
Cell Phone (
Home Phone (
)
E-mail Address
State
F
Zip
County
)
Parent/Guardian’s Name (if participant is under 18)
Address (Street & Apartment No.)
Height/Weight
Relationship to Participant
City
Work Phone (
)
Cell Phone (
Home Phone (
)
E-mail Address
State
Zip
)
EMERGENCY CONTACT INFORMATION
Name
Relationship to Participant
Work Phone (
)
Cell Phone (
Home Phone (
)
E-mail Address
)
Name
Relationship to Participant
Work Phone (
)
Cell Phone (
Home Phone (
)
E-mail Address
)
Expedition Information for the Medical Professional
This is a wilderness experience program for participants that takes place in the
_________________________Alaska. The entire program is conducted in the field. The program will involve
hiking on trails, hiking off trails, camping in mountainous terrain, travel by kayak and chartered plane. Physical
demands on the participant include carrying a backpack of up to 40 lbs while walking over uneven terrain for
_______ miles. Physical demand to control a boat for up to ________miles on Alaska rivers. Participants may be
exposed to inclement and unpredictable weather, mosquitoes, bees, black flies, ticks, or snakes. We will be
sleeping outside for _______ nights. We will possibly climb as high as ________ ft of elevation. Please consider
these activities when evaluating the health of the team member.
ACTIVITY AND DIETARY QUESTIONNAIRE
Is the participant capable of participating in at least a ____ mile uphill hike, carrying a full back pack(up to 40 lbs)
where the pace is set by peers?
FOOD: Does the participant have any special dietary restrictions (vegetarian, dairy products,…).If yes, please
describe:
YES
NO
YES
NO
Please indicate participant's current physical activity level. Check appropriate box and describe below:
Not active
Moderately active (at least 30 minutes per day, 3x or less per week)
Very active (at least 30 minutes per day, more than 3x per week)
HEALTH INFORMATION
Participant’s Physician Name
Phone Number
Location
Participant covered by medical insurance?
Company Name
Phone Number
YES
1.
Date of most recent tetanus shot
NO
Does the participant have any serious medical conditions (including but not limited to asthma,
YES
NO
YES
NO
YES
NO
YES
NO
chest pains, heart problems, diabetes, seizure disorders, pregnancy, significant psychiatric
illness, alcohol or drug problems)? If YES, please describe the nature of the condition, last
occurrence, symptoms and any limitations as a result of the condition:
2.
Does the participant have any significant physical restrictions or recent injuries (within the past
three years) that may impact physical abilities? Examples include strains, fractures, strains etc..If
YES, please describe and how it may impact physical ability:
3.
Is the participant taking any medications? If YES, please list and explain and bring double the
amount the participant will need and give half to the instructor to carry.
4.
Does the participant have any allergies to food, drugs (over-the-counter or prescription), insect
bites or any other allergies? If YES, please describe the allergy and its symptoms and treatment
[if the participant carries an Epi-pen, bring an extra Epi-pen and give it to the instructor to carry]
5.
Has the participant had chest pains, dizziness, or fainted or passed out during exercise? If YES,
YES
NO
please describe:
6.
Does the participant have migraines or other headaches? Medications, frequency, are they
debilitating?
8. Does the applicant have any physical, cognitive, sensory or emotional condition that would
require a special teaching environment? If yes, please describe how the condition affects you:
YES
NO
YES
NO
Please list anything else about the participant that will assist us in contributing to a positive and enriching experience.
Examiner’s Name
Phone
Street Address
State
/
Date:
Physician Signature
Zip
/
By my signature, I attest that the information in this form is correct and the person named on page one of this
form is medically cleared to participate on a program based on the expedition information provided on page 1 of
this form along with the background information provided by the participant and my physical examination of
them.