Hawaii Forms

Medical History Form

Global Treks and Adventures, LLC

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 our staff with information required for course management

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

have the expertise of a medical doctor to assess your physical condition or determine

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)

Legal Name: Phone #:

Preferred Name or Nickname: Pronouns:

Address: Date of Birth:

Emergency Contact Information (Required)

Name: Phone #:

Address: Relationship to Participant:

Email Address:

Medical Insurance Provider (Required)

Provider: Policy #: