Wild and Woolly
P.O. Box 92
Teslin, Yukon Canada YOA 1BO
Trip Name:____________________ Date:____________________
Height: ________ Weight: ________
Sex: ___________ Age: ___________
Health: _____(Excellent) _____(Good) _____(Fair)
Physical Fitness: _____(Excel) _____(Gd) _____(Fr)
Medicine: _____(Yes) _____(No) ________________(Generic Name)
Name of Medical Condition: __________________________________
List any Physical Handicaps: ________________________________
List Allergies or Dietary Restrictions: _____________________
List any condition or illness which effects your participation:
Health Care Number and Provider (Company, State, Province):
I agree that I am fully responsible for the accuracy of my answers and for my own health and physical condition while on the Wild and Woolly wilderness canoe trip.
I have been advised to consider additional insurance and medical coverage.
I understand that this information will be held in strict confidence.
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