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NORM HANN EXPEDITIONS

PERSONAL and MEDICAL INFORMATION

This information is confidential and is for the sole use of the instructors and qualified medical personnel to react appropriately in an emergency. A Release of Claims and this Medical Disclosure Form must be completed and handed to the instructor and discussed as necessary before participating in the program. 

Date: March 21, 2019

Please select who will be participating...
AdultMinor
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First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
MEDICAL INFORMATION

Expedition, Tour or Course Name

In Case of Emergency contact: *

Emergency Contact Phone Number: *

Emergency Contact Email: *

Relationship to Participant: *

Physician Name: *

Carecard # (B.C. Residents only):
Swimming Ability:*
Are you on any medications? (prescription or non-prescription)*

If yes, please specify the medication and what it is for:
Do you have any allergies?*

If Yes, please describe:

Do you have any Chronic disability or illnesses (high blood pressure, heart conditions, epilepsy, diabetes, asthma or others) please list:

History of joint injury (tendonitis, bursitis, sprains, dislocations, or other) please list:

Have you any physical or psychological limitations that would affect your participation in standup paddleboarding? (fear of water, etc.) Please list:

If any of the above information changes prior to, or during the program, I will inform the guides. 

Do you have an food allergies or food issues?*
No
Yes

If yes, please state your food allergies or food issues. *
Where the Participant is a minor, an adult parent of the Participant shall sign for them and by signing, they acknowledge that the waivers, releases and indemnities contained in this Agreement shall apply to the maximum extent allowed by law to the minor Participant.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's 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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