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Pre-Trip Medical Form 

Our kayak tours are for novice to expert kayakers. A level of fitness is required for 4 – 6 hours of paddling per day with rest stops. We will be stopping at many different islands and searching out tide pools and hiking. The ground at times may be uneven and slippery. The purpose of this form is to prepare the leaders of the tour to meet the requirements of our safety procedures, and to reduce the possibility of risks, we need to know about you and your medical history


First Kayaker's Name

First Name*

Last Name*
First Kayaker's Date of Birth*
First Kayaker's Signature*
Second Kayaker's Name

First Name*

Last Name*
Second Kayaker's Date of Birth*
Third Kayaker's Name

First Name*

Last Name*
Third Kayaker's Date of Birth*
Fourth Kayaker's Name

First Name*

Last Name*
Fourth Kayaker's Date of Birth*
Fifth Kayaker's Name

First Name*

Last Name*
Fifth Kayaker's Date of Birth*
Sixth Kayaker's Name

First Name*

Last Name*
Sixth Kayaker's Date of Birth*
Seventh Kayaker's Name

First Name*

Last Name*
Seventh Kayaker's Date of Birth*
Eighth Kayaker's Name

First Name*

Last Name*
Eighth Kayaker's Date of Birth*
Ninth Kayaker's Name

First Name*

Last Name*
Ninth Kayaker's Date of Birth*
Tenth Kayaker's Name

First Name*

Last Name*
Tenth Kayaker's Date of Birth*
Email Address

Email*

Confirm Email*
Pre-Trip Medical Form

Tour Reference Number

Date of Tour

Address

Emergency Contact

Emergency Contact Phone Number

Family Doctor

Family Doctor Phone Number

Medical Insurance Plan Number

Height & Weight
Physical Condition *

Known Allergies (Food, bees etc.), Severity of Allergy and Reaction to Allergen

Medications you will be taking on this trip. Please include the purpose of this medication:
Chronic Conditions (Please check all applicable)
High Blood Pressure
Heart Condition
Epilepsy
Diabetes
Hay Fever/Asthma
Susceptibility

Recent Illness

Year of Last Tetanus Booster

For multi-day trips, current (within the last 10 years), tetanus boosters are mandatory.



History of joint injury (tendonitis, bursitis, sprain, dislocation or other). Please describe and specific which joints:
Eyesight*

* It is required that if you depend upon glasses or contact lenses for adequate vision, you bring a spare set of glasses and safety cords.



Do you have any physical limitations?
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Name

First Name*

Last Name*

Relationship*
Date of Birth*
Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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