WELLS GRAY CHALETS AND WILDERNESS ADVENTURES

MEDICAL FORM

The information contained in this form is confidential and will only be shared with the trip leader and medical personnel in the case of an emergency. No person shall be denied access to any trip based on the following information.

PARTICIPANTS NAME ______________________________________________________________

BIRTHDATE (DMY) _______________WHICH TRIP ARE YOU JOINING?_____________________

DOCTORS NAME _____________________________________ PHONE ______________________

1) Do you have any ALLERGIES such as:

INSECT BITES DRUGS ASTHMA HAYFEVER

OTHER______________________________________________________________________________

2) Are you taking any PRESCRIPTION or NON PRESCRIPTION DRUGS? Y______ N___________

If yes, give details____________________________________________________________________

3)Have you been under a DOCTOR'S CARE in the past year? Y_________ N___________

If yes , give details ___________________________________________________________________

4) Have you had any MAJOR ILLNESSES, INJURIES, OR OPERATIONS?

Y_____ N _____ please specify _________________________________________________________

5) Do you suffer from any CHRONIC CONDITIONS such as :

( ) Diabetes ( ) Epilepsy ( ) Heart condition ( ) Arthritis

( ) Headaches ( ) Fainting ( ) Bronchitis ( ) Sleep Walking

( ) Other; please specify_________________________________________________________________

6) When was your last tetanus inoculation or booster? YEAR ________________

7) Please describe any food allergies or dietary restrictions _____________________________________

_____________________________________________________________________________________

IN CASE OF AN EMERGENCY CONTACT:

NAME ____________________________________ RELATIONSHIP ___________________________

ADDRESS _________________________________ TELEPHONE _____________________________

ALTERNATE NAME: _______________________ RELATIONSHIP ___________________________

ADDRESS _________________________________ TELEPHONE ______________________________

All of the above information is accurate of today's date. If there are any changes between now and the trip, I agree to contact Wells Gray Chalets and Wilderness Adventures with the updated information.

PARTICIPANT'S SIGNITURE __________________________________ DATE__________________

If participant is under 19 years old.

PARENT / GUARDIAN'S SIGNITURE_____________________________ DATE _________________