Information form

Trip/Clinic Info

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Contact Info

Full Name *

Address *

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Home Phone *

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Your Email *

Emergency Contact Info

Full Name *

Who is this person? *

Address *

City *

State *

Zip *

Home Phone

Work Phone

Cell Phone

Email *

Medical Info

Age *

Height *

Weight *

Gender *
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Do you have allergies to food, insects, or medications?
YesNo

Please list what you're allergic to.

How do you react to the allergen?

What medications do you take for this?

Do you have any medical or physical conditions that can affect you during physical exercise?
YesNo

What do you need to manage this condition?

Please list any medications you are currently taking.

Why do you take them?

Please describe any serious injury, illness, or surgery you've had in the last five years.

Other Info

How often and in what activities do you regularly exercise?

Please describe your swimming skills and comfort in mountain lakes and rivers.

Please describe any paddling experience you have.

How did you hear about us?

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