1528 E. Montgomery Ave, Philadelphia, PA 19125
215-543-6171 | Info@ValleyToSummit.com
PARTICIPANT HEALTH FORM
In the interest of the personal safety of both the applicant and the other trip members, please consider the questions carefully when completing the health form. A “Yes” answer does not automatically cancel an applicant’s enrollment. If we have any question on the participant’s capacity to successfully complete the course, we will call the participant to discuss it. Moreover, Valley to Summit, LLC (“VTS”) reserves the right to condition your acceptance to any trip upon the receipt of a written medical clearance from your family physician.
The applicant is not accepted on the trip until the Health Form has been reviewed and approved by VTS personnel, and the applicant has completed and returned all other required forms and payment.
Your detailed comments will expedite our review of this form.
Please check YES or NO for each item. Each Question must be answered and please provide date(s) and details for all “YES” answers.
If yes, please bring one or more metered dose inhaler(s) with you on the trip and an aerochamber/spacer is recommended.
Please list triggers, last episode and hospitalizations?
If yes, please list whether Type I or Type II and please list associated conditions such as neuropathy or retinopathy:
9-13. Describe frequency, date of last episode, and severity:
If yes, please provide cancer type, stage and treatment:
If yes, please provide treatment:
Depending on the applicant's history, risk factors and age, a ECG and/or stress test, waiver or medical clearance from applicant's cardiologist may be required.
Does the applicant currently have or does he/she have a history within the past 3 years of:
Type of injury or surgery? When did the injury or surgery occur?
What is the most rigorous activity participated in since the injury/surgery? Results?
If yes, please provide details:
Applicants with a history of psychotherapy that required medication or has included hospitalization or residential treatment needs to be in a period of stability ranging from six months to two years, depending on the condition, before they will be accepted for a trip. Applicants need to be gainfully occupied such as attending school or employed. VTS is not appropriate for applicants just leaving residential treatment facilities.
Please provide specific dates and details of counseling and psychotherapy history and medications that were prescribed:
31. Name, address and phone number of psychotherapist?
If yes, please describe:
If appropriate, please bring a personal supply (2-3) of epinephrine, preferably in a pre-loaded auto injector ((Epi Pens or Twinjets), and know how to use it.
VTS groups travel in remote areas where access to medical care may be hours or days away. Participants must understand the use of any prescription medications they may be taking. Written specific instructions are necessary. All participants who are required by their personal physician, psychiatrist or health care provider to take prescription medications on a regular basis must be able to do so on their own and without additional supervision.
Please provide a list of Medication, Dosage, Side Effects/Restrictions, Prescribing Doctor, and the Conditions for which the medication is being prescribed.
If Medication or Condition Changes Prior to the start of the Trip, Please Inform VTS as soon as possible.
Please describe: 1) Activities; 2) Frequency; 3) Duration/Distance; and 4) Intensity Level (easy, moderate, competitive)
If so, how much:
By my signature, I the above-named Applicant, attest that the information in this form is correct to the best of my information, knowledge and belief and that I had an opportunity to consult with my physician in regards to completing this form. I further agree that an electronically signed photocopy of this Agreement, or a record of this Agreement sent and received by facsimile, email or other electronic transmission, shall be enforceable and shall have full legal effect as an original.