Form C Trails Club Olympic National Park Participant Application (Page 2 of 2) in pdf

10/19/2012, Form D

TRAILS CLUB OLYMPIC NATIONAL PARK OUTING MEDICAL INFORMATION

Please print your answers clearly. This form will be kept confidential and secure.

Name: __________________________________________________ Date of birth: _________________

Address: _________________________________City: _________________ State: ___ Zip: __________

Phone: _______________________________ Email: __________________________________________

Emergency Contact

Name: __________________________________________ Relationship: __________________________

Phone number(s) _______________________________________________________________________

Doctor's Name: _______________________________________________________________________

Clinic Name & Address: __________________________________________________________________

Phone: _____________________ Fax: ____________________Email: ____________________________

Medical Insurance

Name: ____________________________________ Group/Policy#: ______________________________

Address: ______________________________________________________________________________

Phone: _______________________________________Fax: ____________________________________

The following information is necessary before participation in this Trails Club Outing. It is

essential to have this information in case of illness or accident. Attach additional page if

necessary.

1. Do you have any current medical problems, issues or limitations? No ____Yes ____

If yes, please explain:

2. Have you had any previous medical conditions of which we should be aware? No ___ Yes ___

If yes, please explain:

3. List your current prescriptions, natural, and over-the-counter medication (aspirin & etc.) that you are

now taking or have taken in the last few months: (drug name, dosage and frequency).

_____________________________________________________________________________________

4. Allergies to food, medications, or the environment? No _____ Yes _____ Please list:

5. Current tetanus immunization? No _____Yes _____Please list date:

The Outing leader will keep a copy of this during the outing in case it is needed. Please keep

a copy of this completed form with you at all times during the outing.

Signature of applicant ___________________________________Date ________________

Signature of parent or guardian if applicant is under 18 _________________Date ________

Form C Trails Club Olympic National Park Participant Application Page 2