Medical Form - CoastMountainExpeditions

2022 Medical Registration Form

All information submitted in this form will be kept confidential. We respect your right to medical privacy, but also ask that you remember that his medical form may be critical for guides, paramedics, and doctors to assist you during a medical emergency.

Confidential 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*
Address*
Relationship to participant*
Participant Physical & Medical Information
First & Last Name*
Age*
Height (ft/in)*
Weight (lb)*
Date of Birth*
Medical insurance plan (identify, eg: BC MSP, blue cross etc.)*
Please briefly describe your overall physical condition:*
Allergies - Life Threatening*
If yes, please describe level of sensitivity and reaction:
Allergies - Non Life Threatening*
If yes, please describe level of sensitivity and reaction:
Do you have any dietary restrictions? (Note that we cannot accommodate all dietary needs. Please contact us if you have a restrictive diet; some additional food prep charges may be added)*
If yes, please describe level of sensitivity and required modifications:
Approximate date of last Tetanus inoculation or booster (within 10 years is required)*
Are you currently taking any medication(s) that we should know about, or that are crucial to your health and well-being?*
If yes, specify name of medication(s) (please bring a duplicate set of critical medications for guides to carry).
Have you had any medical procedures that could impact your performance on this trip?*
If yes, please describe:
Do you have any disabilities, illnesses, diseases, or injuries that could impact your performance on this trip?*
If yes, please describe:
Have you received both doses of a Covid 19 vaccine? (vaccination is required for adult trip participants).*
Liability waiver*
- I have reviewed and understand the Coast Mountain Expeditions liability waiver*.
*If under age of 19, liability waiver must be reviewed by parent/guardian.
Covid 19 policies*
- I have reviewed, understand, and accept the Coast Mountain Expeditions Covid 19 policies.
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.
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2022 Medical Registration Form

Confidential Online Registration & Medical Form

In Case of Emergency – Contact:

Participant Physical & Medical Information