Swiftwater Adventures Medical Information Form printable pdf download

Swiftwater Adventures

Medical Information Form

It is essential to your safety and fun that you complete this form for any and all

Swiftwater Adventures trips and activities. Please take the time to accurately complete

this form. In case of emergency this form can supply valuable information to our staff,

guides and medical professionals.

Participants can mail form to:

Swiftwater Adventures 22 E. Riverside Rd. Esko, MN 55733

Participants can also scan and e-mail form to:

Or participants may fill out and complete form prior to trip at check in.

Please fill out neatly and completely. Your life could depend on it. Thanks!

Name___________________________________ Age___ Birthdate_______ Gender M F

Street Address____________________________________________________________

City___________________________________State_______________Zipcode________

Telephone______________________________ E-mail___________________________

In case of emergency notify:________________________________________________

Relationship________________________Telephone____________________________

Do you have medical insurance: Yes No

Medical Insurance Provider:____________________________ Policy #______________

Do you have any physical conditions, which might affect your safety or health on the

trip? Yes

If yes, please explain:______________________________________________________

Please note any history of serious illness such as diabetes, epilepsy, heart condition, past

strokes, or any other previous injuries, or allergies such as foods, hay fever, bee stings,

medications, etc.

________________________________________________________________________

Important Note: We are not medical professionals that are qualified to evaluate your

physical, medical, and/or readiness to participate in any Swiftwater Adventures trip or

activity. If you do have a medical and/or physical condition, please consult with your

physician as to whether or not you are able to participate.

Swiftwater Adventures Medical Information Form