Field Course Forms.pdf

MEDICAL HISTORY FORM

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This information is confidential and will be shared only as needed with

trip leaders, instructors and medical care providers.

This medical form provides us with information required for course management and

emergency situations. By requesting this medical history, we do not imply that we have

the expertise to assess your physical condition, or your ability to participate safely in this

program. If you have any doubts about your ability to participate in this program, please

consult with your physician. Please complete fully so that instructors can adjust program

activities as needed to meet your needs and manage your participation and the

participation of others.

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Participant Information (Required)

Name: Phone #:

Address: Date of Birth:

Emergency Contact Information (Required)

Name: Phone #:

Address: Relationship to Participant:

Height______ Weight______

Allergies: Do you have any allergies (ex: bees, food, drugs, etc.)? Describe the allergy

and the nature of the reaction.

Dietary Needs: Please describe any specific dietary restrictions or needs you would like

us to know about to best support you in the field.

Chronic Illnesses: List any (ex: diabetes, asthma, etc.) and suggest any helpful activity

modifications we should consider.

Medical History Form

Global Treks and Adventures, LLC