Medical Form

Please print out, complete and return by mail with your deposit to:

Dick Person
Wild and Woolly
P.O. Box 92
Teslin, Yukon Canada YOA 1BO

Name: ___________________________________

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.

Signature: ________________________________________

Date: _________________________