2021 Medical Registration Form Kayak Trip Registration Online Registration & Medical FormTrip DescriptionPlease selectKayak Lodge GetawayDiscovery Islands ExplorerDesolation Sound Sea Kayak ExpeditionOctopus Islands AdventureBute Inlet ExpeditionToba Fjordlands ExpeditionOrford River Grizzlies ExpeditionMarine Parks TourCustom TripTrip datesParticipant First & Last Name*Postal Address*City*Province/State/Region*Postal/Zip Code*Country*Email* Enter Email Confirm Email Phone*In Case of Emergency โ Contact:First & Last Name*Phone*Relationship to participant*Participant Physical & Medical InformationFirst & Last Name*Age*Height*Weight*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Medical insurance plan (identify, i.e. blue cross etc.)*Physical condition*Allergies - Life Threatening*YesNoIf yes, please describeAllergies - Non Life Threatening (some food allergies and dietary preferences may incur additional food prep charges)*YesNoIf yes, please describeEyesight (If you are dependent upon glasses for adequate vision, a spare set should be brought with you)*ExcellentGoodFairPoorGlassesContactsDate of last Tetanus inoculation or booster (within 10 years is required)*Are you on any medications?*Yes, prescriptionYes, non-prescriptionNoIf 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)*YesNoDo you have a chronic disability or illness? If yes, please explain.*YesNoDo you have a history of joint injury? If yes, please explain.*YesNoOther injury - please explainDo you have any physical or psychological limitations we should know about?Have you received a Covid 19 vaccine? (Please indicate vaccination date below).*YesNoHave you (or your parent/guardian) read and understood our liability waiver?*YesNoAny 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. Captcha