Name
*
First Name
Last Name
Email Address
*
List any and all medical conditions you have and the date of diagnosis.
*
If you do not have any medical conditions please write N/A.
Please list all prescription medications you take on a regular basis or as needed such as an inhaler.
*
If you do not take any prescription medication please write N/A.
Have you consulted or been treated by physicians, clinics or other medical practitioners within the last two years (other than routine checkups)?
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Yes
No
If yes, Please list diagnosis/treatments/dates:
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If no, please write N/.A
Please list any allergies you may have (medicine, food, insects, etc.)
*
If you do not have allergies please write N/A.
Do you have any dietary restrictions/food allergies?
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Yes
No
Do you wish to request dietary accommodations?
Yes
No
Are these restrictions voluntary or prescribed by a physician?
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Voluntary
Prescribed by Physician
N/A
Please specify what foods you can and cannot eat, i.e. if vegetarian, do you eat fish, dairy, eggs, etc.
*
If you do not have dietary restrictions, please write N/A.
Please check the space below to confirm you will be responsible for bringing the following over-the-counter medications and are capable of taking them. If you have an allergy to any medication listed below and will not be bringing it, please specify the medication and reasons in the space below.
*
*Over-the-Counter Medications:
Pain or fever reducer (e.g. aspirin, acetaminophen, ibuprofen)
Insect Repellent
Topical anti-itch creams (e.g. cortisone cream, antihistamine cream for mosquito bites)
Topical antibacterial cream (to prevent infection on cuts/insect bites)
Cold/cough meds
Allergy meds
Digestive meds (e.g. nausea, diarrhea, antacids)
Motion Sickness meds such as dramamine
Sunscreen
Other
Please list any medications in addition to the above list that you will be bringing
*
If you are not bringing additonal medications, please write N/A/
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone
*
(###)
###
####
Emergency Contact Email
*
BY VOLUNTARY SUBMISSION OF MY ELECTRONIC SIGNATURE, I VERIFY THAT ALL INFORMATION I HAVE SUBMITTED IS COMPLETE AND ACCURATE. I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND AGREE TO ABIDE WITH ALL POLICIES STATED ON THIS FORM, AND I ACKNOWLEDGE THAT MY ELECTRONIC SIGNATURE IS AS VALID AS MY ORIGINAL SIGNATURE.
*
