Wild & Woolly

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

For insurance purposes, in case of illness, hospitalization or medication loss, and for our plans about food, tent and canoe pairing and participation, we need the following information. Please complete and return.

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: _________________________

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