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Overnight Medical Form





First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Medical History

Current Height

Current Weight

Date of Last Physical

Doctor's Name

Doctor's Phone Number

Please list any current health conditions (If None, please state “NONE”):

Please explain any significant injuries, including treatment (If None, please state “NONE”):

Are there any fears, special needs, or recent events in the participant’s life that may impact his/her experience or behavior during outdoor activities? If so, please explain in detail. (If None, please state none)

Do you feel that any aspect of the participant’s mental or physical health may endanger him/herself, the guides, or other members of the group? Are there any activities that may physically or mentally cause too much exertion or anxiety on the participant? If so, please explain in detail. (If None, please state “NONE”):

Are there certain situations, conditions, allergies, foods allergies, or medications that may trigger a negative reaction in the participant? (If None, please state “NONE”):
Does the participant have a history of any of the following medical conditions?
Fainting
Seizures
Panic/anxiety attacks
Headaches
Stomach Aches
Asthma or other breathing problems

Please list any medications that the camper will take, and any possible side effects that may occur.
Does the participant suffer from any form of sleeping disorder (including insomnia or bed wetting)?*
No
Yes
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.
Parent or Guardian's Name

First Name*

Middle 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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