Registration and Medical Form

TRIP REGISTRATION FORM

Trip selected		Sea Kayak Getaway at Coast Mountain Lodge Marine Park & Outer Islands Kayak Tour Desolation Sound Expedition Discovery Islands Sea Kayak Trip Fjordlands Expedition Octopus Islands Expedition Xwemahlkwu Grizzly Bear Expedition
Dates
First name
Last name
Email address
Address
City
Province/State
Postal Code
Country
Telephone Day
Telephone Evening
Applicant's Age
Height
Weight

Emergency Contact:

Name
Address
Phone
Relationship to applicant

If applicant is under 19

Parent's name
Address
Place of employment
Work phone

Note: Parents should sign the medical and waiver form.
Registration should be accompanied by a letter of endorsement from parents.

MEDICAL FORM

Name
Birth date
Medical insurance plan (identify, i.e. blue cross etc.)
Physical condition
Allergies life threatening (none or ?)
Allergies non life threatening (none or ?)
Date of last Tetanus inoculation or booster (within last 10 years recommended).
Are you on any medications (prescription or non-prescription)?		Yes, prescription   Yes, non-prescription   No
If yes, please specify: Name of medications
Reason for medications
Have you been under a doctor's care in the past 12 months?		Yes  No
If yes, please specify

 

Chronic disability or illness (for multiple choice hold down Ctrl key on your keyboard) None High blood pressure Heart condition Epilepsy Diabetes Susceptibility to colds Headaches Nosebleeds Fainting Asthma Hay fever Emphysema

History of joint injury None Tendonitis Bursitis Sprain Dislocation   or others please explain

 

Excellent Good Fair Poor Glasses Contacts

Eyesight (for multiple choice hold down Ctrl key on your keyboard) * If you are dependent upon glasses for adequate vision, a spare set should be brought with you.

 

Do you have any physical limitations ?		Yes  No
if yes, please explain
Do you have any psychological limitations?		Yes  No
if yes, please explain
The above medical information is complete and accurate. If any of the information changes, I will inform the instructors so that the changes can be recorded. I have read the trip outline and physical requirements. I am in good physical condition to participate. I have read the disclosure information and understand the possible hazards that may be encountered on the trip. I agree to adhere to the rules and regulations set up by the leaders of the trip to minimize risk and ensure safety. I have read the Disclaimer of Liability of Coast Mountain Expeditions. Ltd. and agree to be bound by its terms and conditions.

Name of Applicant
Date
Parent's Name  ( * fill in full name if applicant under 19)
Date

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