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AGI Participant Medical Information

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Full Name: * Trip of Interest: * Mailing: * Home Address: * Email: * Phone Cell: * Person to contact in case of an emergency: Full Name: * Relationship to you: * Mailing: * Email: * Phone Cell: *

Mountain travel by means of hiking, climbing, skiing and mountain biking is very strenuous and hard on the body. It is important that you are in good physical fitness and that your Dr. would approve of such a trip based on your current health. It is important that the following information you provide is honest and accurate!

What would you rate your fitness level at? exceptionally fit, above average, average, below average: * Please list any accidents, illnesses or operations you have had in the last 5 years. * Do you have any allergies (e.g., bee stings, iodine, drugs, food)? * Yes: No:

Specify and include a brief description of reaction:

Are you taking any medications? * Yes: No:

List all medications & the condition they are for:

What would you rate your fitness level at? exceptionally fit, above average, average, below average: * Do you have History of any chronic illnesses (e.g., diabetes, asthma, epilepsy, heart condition)? * Yes: No:

Please specify and describe symptoms:

Do you have any other physical conditions or disabilities that might limit your physical participation (e.g., shoulder problems, ankle or knee problems, back or neck problems)? Yes: No:

Specify:

Do you wear contact lenses? Yes: No:

Have you had a tetanus shot within the past 10 years? Yes: No:

Do you have Health Insurance? Yes: No:

Do you have Rescue Insurance? Yes: No:

Authorization for Emergency Medical Care

I affirm that my health is good and that I am not under a physician's care for any condition that bears upon my fitness to participate in the mountain based activities such as: Rock, Ice, Alpine and High Altitude Climbing, Backcountry Skiing, Ski Mountaineering and Touring and Mountain Biking. I hereby give permission for Alpine Guides International staff to render to me or seek for me first aid or emergency medical treatment in the event of injury or illness during the activity, including transportation by helicopters, animals, ambulance and hospitalization. I will be responsible for any and all costs of medical attention and treatment.

Participant's Signature: * Date: * Signature of Parent/Guardian of Participant (if under 18yrs): * Date: *

Alpine Guides International
Mark Puleio
[email protected]
101 Commonwealth Ave
Hyde Park, VT 05655