Trips & Course Medical/Diet Info Form Please note that this is not a registration form but a diet and medical form for you to fill out after you have registered for an instruction program or a trip.Name:* First Last Email:* Mailing Address including postal/zip code*Trip/Program Name:*Trip/Program Dates:*Your Birthdate:* Month Day Year Gender: Male Female Prefer Not to Answer Best number to contact you at:Best time to contact you: Anytime is great! Morning (between 9:00-11am EST) Afternoon (between 1-5pm EST) Evening (after 6pm EST) Emergency Contact Info:Emergency Contact Name:* First Last Relationship:*Emergency Contact Phone:Other ways to contact this person:Health Provider Info:Canada: Health Card Number:Other: Provider, Policy #, Contact Info:Date of last Tetanus Shot:Recommended every 10 years. Month Day Year Skills Self Evaluation 1=Weak and 5=ExcellentGeneral Health: 1 2 3 4 5 Level Of Fitness: 1 2 3 4 5 Canoe/Kayak Experience: 1 2 3 4 5 Swimming Ability: 1 2 3 4 5 Hiking Ability: 1 2 3 4 5 Wilderness Camping Experience: 1 2 3 4 5 Please describe any medical or physical health conditions that may affect your participation including any recent injuries and/or major illnesses:Please let us know any mental health conditions or psychological limitations, past or present that may affect your participation. (e.g.: anxiety, panic attacks, specific phobias, depression etc)If yes; is there any helpful information that your guide/instructor should be made aware of? (stressors, coping strategies etc)In the case you require medical attention, please list any regular medications you are taking and for what condition:Please list any food, drug and environmental allergies (including your reaction and severity if exposed):Please tell us any dietary restrictions you may have.What are you most looking forward to with this program?Let us know if you have any concerns with your upcoming program.PhoneThis field is for validation purposes and should be left unchanged.