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EMERGENCY CONTACT & MEDICAL FORM

MOUNT ASSINIBOINE LODGE LTD.


 

Please complete the following form for each individual in your party.


First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Date of arrival at Assiniboine Lodge: *

Body Weight in pounds (required by Transport Canada for the helicopter). *

DIETARY RESTRICTIONS & ALLERGIES - Please describe if you have any food restrictions or allergies. NOTE - we will make an effort to accommodate dietary allergies, but as our kitchen regularly cooks with wheat flour and nuts, we are not able to guarantee that food will be free of these or other allergens. Due to the high number of special dietary requests and only one chef on staff, your restriction(s) may be grouped in with other restrictions. For example, if you can't eat red meat, you may be given a vegan option. You will be asked to eat around your restriction(s) when there are other options available. Please bring your own bread, and snacks(cookies, granola bars, etc.) if your diet restrictions/allergens are commonly found in these items. This is the best way to ensure there is no cross-contamination.

MEDICAL INFORMATION 

DO YOU HAVE AN ANAPHYLACTIC ALLERGY? *Please Note - Helicopter rescues are not always possible due to bad weather, darkness or the rescue helicopter being tied up on another rescue. We therefore recommend that people with anaphylactic allergies, that may be present in the lodge environment, do not come to the lodge in order to prevent a situation that may result in death. Please contact us if you wish to discuss this recommendation further.*
No
Yes

If you have an anaphylactic allergy please provide details

MEDICATIONS

MEDICAL CONDITIONS - If you have a medical condition, please describe. If you require a CPAP Machine please make sure it's battery operated as there is no electricity in your accommodation. If you have an unstable medical condition, we recommend that you seriously consider not coming to the lodge. Please consult your doctor if unsure.
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Date of arrival at Assiniboine Lodge: *

Body Weight in pounds (required by Transport Canada for the helicopter). *

DIETARY RESTRICTIONS & ALLERGIES - Please describe if you have any food restrictions or allergies. NOTE - we will make an effort to accommodate dietary allergies, but as our kitchen regularly cooks with wheat flour and nuts, we are not able to guarantee that food will be free of these or other allergens. Due to the high number of special dietary requests and only one chef on staff, your restriction(s) may be grouped in with other restrictions. For example, if you can't eat red meat, you may be given a vegan option. You will be asked to eat around your restriction(s) when there are other options available. Please bring your own bread, and snacks(cookies, granola bars, etc.) if your diet restrictions/allergens are commonly found in these items. This is the best way to ensure there is no cross-contamination.

MEDICAL INFORMATION 

DO YOU HAVE AN ANAPHYLACTIC ALLERGY? *Please Note - Helicopter rescues are not always possible due to bad weather, darkness or the rescue helicopter being tied up on another rescue. We therefore recommend that people with anaphylactic allergies, that may be present in the lodge environment, do not come to the lodge in order to prevent a situation that may result in death. Please contact us if you wish to discuss this recommendation further.*
No
Yes

If you have an anaphylactic allergy please provide details

MEDICATIONS

MEDICAL CONDITIONS - If you have a medical condition, please describe. If you require a CPAP Machine please make sure it's battery operated as there is no electricity in your accommodation. If you have an unstable medical condition, we recommend that you seriously consider not coming to the lodge. Please consult your doctor if unsure.
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Date of arrival at Assiniboine Lodge: *

Body Weight in pounds (required by Transport Canada for the helicopter). *

DIETARY RESTRICTIONS & ALLERGIES - Please describe if you have any food restrictions or allergies. NOTE - we will make an effort to accommodate dietary allergies, but as our kitchen regularly cooks with wheat flour and nuts, we are not able to guarantee that food will be free of these or other allergens. Due to the high number of special dietary requests and only one chef on staff, your restriction(s) may be grouped in with other restrictions. For example, if you can't eat red meat, you may be given a vegan option. You will be asked to eat around your restriction(s) when there are other options available. Please bring your own bread, and snacks(cookies, granola bars, etc.) if your diet restrictions/allergens are commonly found in these items. This is the best way to ensure there is no cross-contamination.

MEDICAL INFORMATION 

DO YOU HAVE AN ANAPHYLACTIC ALLERGY? *Please Note - Helicopter rescues are not always possible due to bad weather, darkness or the rescue helicopter being tied up on another rescue. We therefore recommend that people with anaphylactic allergies, that may be present in the lodge environment, do not come to the lodge in order to prevent a situation that may result in death. Please contact us if you wish to discuss this recommendation further.*
No
Yes

If you have an anaphylactic allergy please provide details

MEDICATIONS

MEDICAL CONDITIONS - If you have a medical condition, please describe. If you require a CPAP Machine please make sure it's battery operated as there is no electricity in your accommodation. If you have an unstable medical condition, we recommend that you seriously consider not coming to the lodge. Please consult your doctor if unsure.
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Date of arrival at Assiniboine Lodge: *

Body Weight in pounds (required by Transport Canada for the helicopter). *

DIETARY RESTRICTIONS & ALLERGIES - Please describe if you have any food restrictions or allergies. NOTE - we will make an effort to accommodate dietary allergies, but as our kitchen regularly cooks with wheat flour and nuts, we are not able to guarantee that food will be free of these or other allergens. Due to the high number of special dietary requests and only one chef on staff, your restriction(s) may be grouped in with other restrictions. For example, if you can't eat red meat, you may be given a vegan option. You will be asked to eat around your restriction(s) when there are other options available. Please bring your own bread, and snacks(cookies, granola bars, etc.) if your diet restrictions/allergens are commonly found in these items. This is the best way to ensure there is no cross-contamination.

MEDICAL INFORMATION 

DO YOU HAVE AN ANAPHYLACTIC ALLERGY? *Please Note - Helicopter rescues are not always possible due to bad weather, darkness or the rescue helicopter being tied up on another rescue. We therefore recommend that people with anaphylactic allergies, that may be present in the lodge environment, do not come to the lodge in order to prevent a situation that may result in death. Please contact us if you wish to discuss this recommendation further.*
No
Yes

If you have an anaphylactic allergy please provide details

MEDICATIONS

MEDICAL CONDITIONS - If you have a medical condition, please describe. If you require a CPAP Machine please make sure it's battery operated as there is no electricity in your accommodation. If you have an unstable medical condition, we recommend that you seriously consider not coming to the lodge. Please consult your doctor if unsure.
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Date of arrival at Assiniboine Lodge: *

Body Weight in pounds (required by Transport Canada for the helicopter). *

DIETARY RESTRICTIONS & ALLERGIES - Please describe if you have any food restrictions or allergies. NOTE - we will make an effort to accommodate dietary allergies, but as our kitchen regularly cooks with wheat flour and nuts, we are not able to guarantee that food will be free of these or other allergens. Due to the high number of special dietary requests and only one chef on staff, your restriction(s) may be grouped in with other restrictions. For example, if you can't eat red meat, you may be given a vegan option. You will be asked to eat around your restriction(s) when there are other options available. Please bring your own bread, and snacks(cookies, granola bars, etc.) if your diet restrictions/allergens are commonly found in these items. This is the best way to ensure there is no cross-contamination.

MEDICAL INFORMATION 

DO YOU HAVE AN ANAPHYLACTIC ALLERGY? *Please Note - Helicopter rescues are not always possible due to bad weather, darkness or the rescue helicopter being tied up on another rescue. We therefore recommend that people with anaphylactic allergies, that may be present in the lodge environment, do not come to the lodge in order to prevent a situation that may result in death. Please contact us if you wish to discuss this recommendation further.*
No
Yes

If you have an anaphylactic allergy please provide details

MEDICATIONS

MEDICAL CONDITIONS - If you have a medical condition, please describe. If you require a CPAP Machine please make sure it's battery operated as there is no electricity in your accommodation. If you have an unstable medical condition, we recommend that you seriously consider not coming to the lodge. Please consult your doctor if unsure.
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Date of arrival at Assiniboine Lodge: *

Body Weight in pounds (required by Transport Canada for the helicopter). *

DIETARY RESTRICTIONS & ALLERGIES - Please describe if you have any food restrictions or allergies. NOTE - we will make an effort to accommodate dietary allergies, but as our kitchen regularly cooks with wheat flour and nuts, we are not able to guarantee that food will be free of these or other allergens. Due to the high number of special dietary requests and only one chef on staff, your restriction(s) may be grouped in with other restrictions. For example, if you can't eat red meat, you may be given a vegan option. You will be asked to eat around your restriction(s) when there are other options available. Please bring your own bread, and snacks(cookies, granola bars, etc.) if your diet restrictions/allergens are commonly found in these items. This is the best way to ensure there is no cross-contamination.

MEDICAL INFORMATION 

DO YOU HAVE AN ANAPHYLACTIC ALLERGY? *Please Note - Helicopter rescues are not always possible due to bad weather, darkness or the rescue helicopter being tied up on another rescue. We therefore recommend that people with anaphylactic allergies, that may be present in the lodge environment, do not come to the lodge in order to prevent a situation that may result in death. Please contact us if you wish to discuss this recommendation further.*
No
Yes

If you have an anaphylactic allergy please provide details

MEDICATIONS

MEDICAL CONDITIONS - If you have a medical condition, please describe. If you require a CPAP Machine please make sure it's battery operated as there is no electricity in your accommodation. If you have an unstable medical condition, we recommend that you seriously consider not coming to the lodge. Please consult your doctor if unsure.
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Date of arrival at Assiniboine Lodge: *

Body Weight in pounds (required by Transport Canada for the helicopter). *

DIETARY RESTRICTIONS & ALLERGIES - Please describe if you have any food restrictions or allergies. NOTE - we will make an effort to accommodate dietary allergies, but as our kitchen regularly cooks with wheat flour and nuts, we are not able to guarantee that food will be free of these or other allergens. Due to the high number of special dietary requests and only one chef on staff, your restriction(s) may be grouped in with other restrictions. For example, if you can't eat red meat, you may be given a vegan option. You will be asked to eat around your restriction(s) when there are other options available. Please bring your own bread, and snacks(cookies, granola bars, etc.) if your diet restrictions/allergens are commonly found in these items. This is the best way to ensure there is no cross-contamination.

MEDICAL INFORMATION 

DO YOU HAVE AN ANAPHYLACTIC ALLERGY? *Please Note - Helicopter rescues are not always possible due to bad weather, darkness or the rescue helicopter being tied up on another rescue. We therefore recommend that people with anaphylactic allergies, that may be present in the lodge environment, do not come to the lodge in order to prevent a situation that may result in death. Please contact us if you wish to discuss this recommendation further.*
No
Yes

If you have an anaphylactic allergy please provide details

MEDICATIONS

MEDICAL CONDITIONS - If you have a medical condition, please describe. If you require a CPAP Machine please make sure it's battery operated as there is no electricity in your accommodation. If you have an unstable medical condition, we recommend that you seriously consider not coming to the lodge. Please consult your doctor if unsure.
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Date of arrival at Assiniboine Lodge: *

Body Weight in pounds (required by Transport Canada for the helicopter). *

DIETARY RESTRICTIONS & ALLERGIES - Please describe if you have any food restrictions or allergies. NOTE - we will make an effort to accommodate dietary allergies, but as our kitchen regularly cooks with wheat flour and nuts, we are not able to guarantee that food will be free of these or other allergens. Due to the high number of special dietary requests and only one chef on staff, your restriction(s) may be grouped in with other restrictions. For example, if you can't eat red meat, you may be given a vegan option. You will be asked to eat around your restriction(s) when there are other options available. Please bring your own bread, and snacks(cookies, granola bars, etc.) if your diet restrictions/allergens are commonly found in these items. This is the best way to ensure there is no cross-contamination.

MEDICAL INFORMATION 

DO YOU HAVE AN ANAPHYLACTIC ALLERGY? *Please Note - Helicopter rescues are not always possible due to bad weather, darkness or the rescue helicopter being tied up on another rescue. We therefore recommend that people with anaphylactic allergies, that may be present in the lodge environment, do not come to the lodge in order to prevent a situation that may result in death. Please contact us if you wish to discuss this recommendation further.*
No
Yes

If you have an anaphylactic allergy please provide details

MEDICATIONS

MEDICAL CONDITIONS - If you have a medical condition, please describe. If you require a CPAP Machine please make sure it's battery operated as there is no electricity in your accommodation. If you have an unstable medical condition, we recommend that you seriously consider not coming to the lodge. Please consult your doctor if unsure.
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Date of arrival at Assiniboine Lodge: *

Body Weight in pounds (required by Transport Canada for the helicopter). *

DIETARY RESTRICTIONS & ALLERGIES - Please describe if you have any food restrictions or allergies. NOTE - we will make an effort to accommodate dietary allergies, but as our kitchen regularly cooks with wheat flour and nuts, we are not able to guarantee that food will be free of these or other allergens. Due to the high number of special dietary requests and only one chef on staff, your restriction(s) may be grouped in with other restrictions. For example, if you can't eat red meat, you may be given a vegan option. You will be asked to eat around your restriction(s) when there are other options available. Please bring your own bread, and snacks(cookies, granola bars, etc.) if your diet restrictions/allergens are commonly found in these items. This is the best way to ensure there is no cross-contamination.

MEDICAL INFORMATION 

DO YOU HAVE AN ANAPHYLACTIC ALLERGY? *Please Note - Helicopter rescues are not always possible due to bad weather, darkness or the rescue helicopter being tied up on another rescue. We therefore recommend that people with anaphylactic allergies, that may be present in the lodge environment, do not come to the lodge in order to prevent a situation that may result in death. Please contact us if you wish to discuss this recommendation further.*
No
Yes

If you have an anaphylactic allergy please provide details

MEDICATIONS

MEDICAL CONDITIONS - If you have a medical condition, please describe. If you require a CPAP Machine please make sure it's battery operated as there is no electricity in your accommodation. If you have an unstable medical condition, we recommend that you seriously consider not coming to the lodge. Please consult your doctor if unsure.
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Date of arrival at Assiniboine Lodge: *

Body Weight in pounds (required by Transport Canada for the helicopter). *

DIETARY RESTRICTIONS & ALLERGIES - Please describe if you have any food restrictions or allergies. NOTE - we will make an effort to accommodate dietary allergies, but as our kitchen regularly cooks with wheat flour and nuts, we are not able to guarantee that food will be free of these or other allergens. Due to the high number of special dietary requests and only one chef on staff, your restriction(s) may be grouped in with other restrictions. For example, if you can't eat red meat, you may be given a vegan option. You will be asked to eat around your restriction(s) when there are other options available. Please bring your own bread, and snacks(cookies, granola bars, etc.) if your diet restrictions/allergens are commonly found in these items. This is the best way to ensure there is no cross-contamination.

MEDICAL INFORMATION 

DO YOU HAVE AN ANAPHYLACTIC ALLERGY? *Please Note - Helicopter rescues are not always possible due to bad weather, darkness or the rescue helicopter being tied up on another rescue. We therefore recommend that people with anaphylactic allergies, that may be present in the lodge environment, do not come to the lodge in order to prevent a situation that may result in death. Please contact us if you wish to discuss this recommendation further.*
No
Yes

If you have an anaphylactic allergy please provide details

MEDICATIONS

MEDICAL CONDITIONS - If you have a medical condition, please describe. If you require a CPAP Machine please make sure it's battery operated as there is no electricity in your accommodation. If you have an unstable medical condition, we recommend that you seriously consider not coming to the lodge. Please consult your doctor if unsure.
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

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

Date of arrival at Assiniboine Lodge: *

Body Weight in pounds (required by Transport Canada for the helicopter). *

DIETARY RESTRICTIONS & ALLERGIES - Please describe if you have any food restrictions or allergies. NOTE - we will make an effort to accommodate dietary allergies, but as our kitchen regularly cooks with wheat flour and nuts, we are not able to guarantee that food will be free of these or other allergens. Due to the high number of special dietary requests and only one chef on staff, your restriction(s) may be grouped in with other restrictions. For example, if you can't eat red meat, you may be given a vegan option. You will be asked to eat around your restriction(s) when there are other options available. Please bring your own bread, and snacks(cookies, granola bars, etc.) if your diet restrictions/allergens are commonly found in these items. This is the best way to ensure there is no cross-contamination.

MEDICAL INFORMATION 

DO YOU HAVE AN ANAPHYLACTIC ALLERGY? *Please Note - Helicopter rescues are not always possible due to bad weather, darkness or the rescue helicopter being tied up on another rescue. We therefore recommend that people with anaphylactic allergies, that may be present in the lodge environment, do not come to the lodge in order to prevent a situation that may result in death. Please contact us if you wish to discuss this recommendation further.*
No
Yes

If you have an anaphylactic allergy please provide details

MEDICATIONS

MEDICAL CONDITIONS - If you have a medical condition, please describe. If you require a CPAP Machine please make sure it's battery operated as there is no electricity in your accommodation. If you have an unstable medical condition, we recommend that you seriously consider not coming to the lodge. Please consult your doctor if unsure.
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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