AGI Participant Medical Information

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Person to contact in case of an emergency:

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!

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Specify and include a brief description of reaction:

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List all medications & the condition they are for:

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Please specify and describe symptoms:

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Specify:

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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.



Alpine Guides International
Mark Puleio
mark@alpineguidesinternational.com
101 Commonwealth Ave
Hyde Park, VT 05655
802 585 9061 (+33) 0618236378