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:* 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, physical or mental health conditions that we should be aware of that may affect your participation in this program, including any recent injuries and/or major illnesses: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, preferences and dislikes:What are you most looking forward to with this program and do you have any concerns?CommentsThis field is for validation purposes and should be left unchanged.