Evergreen : Health & Diet Form

Personal Information

* Gender:

Male

Female

* Birthdate:

/ /

* Full Name:

* Telephone:

* Email Address:

* School Name:

Full Address:

Medical Conditions

Please select any of the following conditions that apply to you. Please select "Other" if you have any conditions that may affect your participation in outdoor activities.

	Breathing Condition		Diabetes		Hemophilia
	Neck/Back Problems		Asthma		Past Operations **

Other:

** Past operations within six months.

If you selected any of the above, please indicate below the specifics of your condition including severity, possible medications, last occurrence, as well as any information that may affect your participation in an outdoor activities.

Describe:

Other Important Information

* Are you currently taking any medications?

Yes

If 'Yes' please describe:

* Do you have any allergies?

Yes

If 'Yes' please describe:

* Do you have any major dietary concerns or specific issues?

Yes

If 'Yes' please describe:

Consent & Signature

By checking this box, I agree that the information given is true and accurate to the best of my knowledge.

Signed By (Please provide your initials in the above box.)

All the information given is completely confidential and will only be used by Evergreen Adventures for the purpose of maintaining the safety and well being of participants at all times. Evergreen Adventures will hold this information in the strictest of confidence.