Medical Form - CoastMountainExpeditions

Online Registration & Medical Form

Trip Description

Trip dates

Participant First & Last Name*

Postal Address*

City*

Province/State/Region*

Postal/Zip Code*

Country*

Email*

Enter Email Confirm Email

Phone*

In Case of Emergency – Contact:

First & Last Name*

Phone*

Relationship to participant*

Participant Physical & Medical Information

First & Last Name*

Age*

Height*

Weight*

Date of Birth*

Medical insurance plan (identify, i.e. blue cross etc.)*

Physical condition*

Allergies - Life Threatening*

If yes, please describe

Allergies - Non Life Threatening*

If yes, please describe

Eyesight (If you are dependent upon glasses for adequate vision, a spare set should be brought with you)*

Date of last Tetanus inoculation or booster (within 10 years may be required)*

Are you on any medications?*

If yes, please specify: Name of medications (Prescription and non-prescription)

Have you been under a doctor's care in the past 12 months? (If yes, please specify)*

Do you have a chronic disability or illness? If yes, please explain.*

Do you have a history of joint injury? If yes, please explain.*

Other injury - please explain

Do you have any physical or psychological limitations we should know about?

Any additional information you wish to add:

The medical information I have submitted is complete and accurate. If any of my information changes, I will inform Coast Mountain Expeditions ahead of the trip. I agree to follow rules and requests of the trip leaders whose job is to minimize risk and ensure safety. I have read the disclosure information and understand the possible hazards that may be encountered on the trip. I have read the trip outline and physical requirements and I am in good physical condition to participate. I have read the Disclaimer of Liability of Coast Mountain Expeditions. Ltd. and agree to be bound by its terms and conditions. I will sign the liability waiver on arrival and provide guardian/parent consent for any participant under 19 who is traveling in my care.

Participant First & Last Name*

Date*

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2018 Medical Registration Form

Online Registration & Medical Form

In Case of Emergency – Contact:

Participant Physical & Medical Information