Day Trips
Paddle
Guided Sea Kayak Trips on Lake Superior
Lake Superior Voyageur Canoe
Learn
Overview & Booking
Sea Kayak
Tandem Canoe
Stand up Paddleboard (SUP)
Wilderness First Aid ~2018
Unique
Gallery
Resources
Driving Directions
What to Bring
Terms and Conditions
Important Forms
Canadian Canoe Culture
FAQs
About Us
Contact Us
Our Staff and Friends
Work with us
Rentals & Shuttles
Accommodations
Blog
Links
Youth (under 18) Medical Information Form
Youth (under 18) Medical Information Form
Confidential. For staff/administration use only!
Child's Name:
*
First
Last
Trip/Program Name:
*
Trip/Program Dates:
*
Your Childs Birthdate:
*
Month
Day
Year
Gender:
Male
Female
Parent/Guardian Contact Info
Parent Email:
*
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)
Parent or Guardian's Name #1:
*
First
Last
Parent or Guardian's Name #2:
*
First
Last
Parent/Guardian #1 Phone Number (home):
Parent/Guardian #1 Phone Number (work):
Parent/Guardian #2 Phone Number (home):
Parent/Guardian #2 Phone Number (work):
Emergency Contact Info
Emergency Contact Name:
*
First
Last
Relationship:
*
Emergency Contact Phone:
Other ways to contact this person:
Health Provider Info
Health Care Provider:
Policy Number:
Doctor's Name:
Doctor's Phone Number:
Date of last Tetanus Shot:
Month
Day
Year
Recommended every 10 years.
Does your child wear glasses?
Yes
No
Does your child wear contact lenses?
Yes
No
Does your child have any allergies that our staff should be aware of? (Check any that apply.)
Penicliin
Aspirin
Tylenol
Plants
Insect Bites
Bee Stings
Any other drugs
Does your child have any food allergies/intolerances? Please describe:
Please indicate if your child has any of the following conditions (check any that apply):
Asthma
Fainting
Headaches
Fainting
Toothaches
Earaches
Cramps
Re-current bone, joint/muscle injuries
Sleepwalking/talking
Susceptibility to cold
If yes to any of the above, please explain:
Does your child take any medications?
*
Yes
No
Please explain when and how they are to be taken:
*
Are there any behavioral/mental health problems that we should know about?
*
Yes
No
If yes, please explain what they are and how we can best deal with them:
*
Is there anything else you would like us to know about your child?
I agree that the information I have provided is correct and complete to the best of my knowledge.
*
I agree
This iframe contains the logic required to handle Ajax powered Gravity Forms.