| Medical Information Form (*ONE FORM MUST BE FILLED OUT PER PERSON) |
| Many of our programs take place in remote settings where rescue is difficult and definitive medical care is far away. Additionally, most of our outings require a high level of physical activity for a considerable length of time. We use the information on this form to help you sign up for an appropriate program and to facilitate treatment should a problem arise. If we have any question about your ability to safely complete a program we will call and discuss the issue with you. You may be asked to consult a physician. All information on this form is kept confidential. |
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| Trip Registrant: |
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| Trip: |
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| Trip Dates: |
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| First Name: |
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| Last Name: |
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| Date of Birth: (MM/DD/YYYY) |
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| Height: |
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| Weight: |
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| Gender: |
Male
Female |
| Home Phone: |
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| Work Phone: |
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| Cell Phone: |
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| Address: |
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| City: |
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| State: |
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| Zip: |
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| Email: |
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| Emergency Contact: |
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| Relationship to You: |
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| Emergency Contact Primary Phone: |
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| Emergency Contact Secondary Phone: |
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| Emergency Contact Email: |
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If this is a program where SMC is providing food, do you have
any
special dietary needs or requests? |
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| Physician's Name: |
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| Physician's Phone: |
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| Health insurance provider *: |
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| Health insurance Policy #: |
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| Please describe your physical conditioning program, if any : |
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| Please describe your physical condition: |
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MEDICAL HISTORY
Do you now have, or have you had within the past two years,
any of the following conditions? If “yes” to any of the conditions below,
please explain in the space provided. |
| Condition |
Yes |
No |
Condition |
Yes |
No |
| Altitude Illness |
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Diagnosed Mental Illness |
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| Broken Bones |
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Severe Anxiety or Depression |
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| Severe Sprains |
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High Blood Pressure |
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| Shoulder or Neck Problem |
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Heart Disease |
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| Back Problem |
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Seizure Disorder |
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| Foot or Ankle Problem |
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Asthma |
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| Leg or Knee Problem |
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Diabetes |
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| Arm or Hand Problem |
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Chronic Headaches |
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| Intestinal Problem |
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Shortness of Breath |
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| Urinary Tract Problem |
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Chest Pain |
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| Heat or Cold Intolerance |
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Hospitalization in Past Year |
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Uncorrected Vision or Hearing
Impairment |
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Women only: Are you
currently pregnant? |
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Please elaborate on any “Yes” response from above:
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| Are you currently taking any prescription medications? |
Yes
No |
| If yes, please list medications and dosage: |
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| Are you allergic to any foods, insect bites, medications, or other? |
Yes
No |
| If yes, please explain what you are allergic to, the reaction, and treatment required. |
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| Do you have any other condition that could affect your performance during physical activity, including your ability to run, lift, climb, or ski? |
Yes
No |
| If yes, please describe. |
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| Please describe in detail your previous relevant outdoor activities: Rock/ice climbing, skiing, backcountry skiing, mountaineering, wilderness hiking, gym climbing etc… |
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IMPORTANT! PLEASE READ:
Indicate you have read & agree to our Participant Agreement, Release and Assumption of Risk
Scroll through and read the agreement, then type in the box
I AGREE (all caps)
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IMPORTANT! PLEASE READ:
Indicate you have read & agree to our Cancellation Policy
Scroll through and read the agreement,
then type in the box
I AGREE (all caps)
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TRAVEL INSURANCE
We strongly recommend obtaining trip cancellation insurance (Travel Insurance)
You can download the Adventure Insurance Brochure here, go to the Travelguard Website or call us for more info.
Yes, I have purchased travel insurance.
No, I have not and will not purchase travel insurance.
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PHOTOGRAPHIC MODEL RELEASE
We often use photographic images from our trips in slide shows, brochures, and other advertising. Please initial here if you agree that we can use photos of you from your SMC trip in this manner. |
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ONLINE SIGNATURE
All of the information given to Sierra Mountain Center on this form is complete and accurate to the best of my knowledge. |
| Participant Initials: |
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| Initials of Parent/Guardian (if participant is under age 18): |
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