Medical Form - CoastMountainExpeditions

2024 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 information submitted may be critical for guides, paramedics, and doctors to assist you during a medical emergency. The more information we have, the better we can help you.

Confidential Online Registration & Medical Form
Trip Description
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:*

Hint: Do you consider yourself fit for your age? Do you exercise regularly?
Allergies - Life Threatening*
Please state the allergy and describe level of sensitivity and reaction:

Hint: More information is critical here: Have you had a reaction? If so, when did it happen last? Have you ever used an epi-pen or gone to the hospital? Do you carry an epi-pen? How sensitive are you to the allergen?
Allergies - Non Life Threatening*
Please state the allergy and describe level of sensitivity and reaction:

Hint: More detail helps us to plan and prepare, especially if it's possible that you'll encounter the allergen on the trip. What's your reaction like? How sensitive are you to the allergen?
Do you have any dietary restrictions? (Note that we cannot accommodate all dietary needs, or simple "likes/dislikes". Please contact us if you have complex dietary needs.*
How sensitive are you to the food item/ingredient?

Hint: More information helps us to plan and prepare.
Please describe the extent of modifications you require:

Hint: More information helps us to plan and prepare. Are your dietary needs flexible? If so, how much? Eg. some people can tolerate small amounts, but not a lot.
Please select a special diet, if required:
While we do our best to provide great food for everyone, those requiring modifications can expect a bit less meal/snack variety.
Is your Tetanus inoculation up-to-date (within 10 years required for expedition trips).*
Tetanus inoculation is recommended for the Surge Narrows Lodge Getaway, but not required.
Are you currently taking any medication(s) that we should know about, or that are crucial to your health and well-being?*
Hint: If you need medications to maintain your quality of life or to stay alive, we should know about them.
Please specify name & purpose of medication(s) (bring a duplicate set of critical medications for guides to carry).

Did we mention to bring a duplicate set? It's easy to lose stuff out there!
Have you had any medical procedures that could impact your performance on this trip?*
Please describe:
Do you have any disabilities, illnesses, or diseases that could impact your performance on this trip?*
Please describe:
Do you have, or have you had any injuries that could impact your performance on this trip?*
Please describe:
Other information
What is your preferred room/tent arrangement?*
We may not be able to accommodate all preferences (some camping spots don't have a lot of tent sites), but will do our best.
Who will you share your room/tent with?
Will you require a sleeping bag rental?
- Sleeping bag rental ($5+tax/night)
Liability waiver*
- I have read and agree to the Coast Mountain Expeditions liability waiver*.
*If under age of 19, liability waiver must be read and agreed to by a parent/guardian.
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 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 liability waiver 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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2024 Medical Registration Form

Confidential Online Registration & Medical Form

In Case of Emergency – Contact:

Participant Physical & Medical Information

Other information