Participant Medical and Personal Information Form
OCEAN LIGHT ADVENTURES LTD. MEDICAL AND PERSONAL INFORMATION FORM
Please complete this form to the best of your ability as it is in the best interest of yourself, your fellow trip members, and your guides that all of the information provided is accurate and complete. Completion of this form is mandatory for trip participation and must be returned at least 30 days prior to departure. Your answers are for our records and will be considered absolutely confidential.
Participant's Name: Today's Date:
Trip Name: Trip Start Date:
Date of Birth: Gender: Height: Weight:
Emergency Contact Name: Phone: Name of Phsyician: Physician Phone:
Please evaluate your:
Swimming Ability: Non-swimmerPoorFairGoodExcellent
Has there been a change in your general health this past year? YesNo
Are you now under the care of a physician? YesNo
Have you been hospitalized or had serious injury within the past 5 years? YesNo
Do you wear contact lenses? YesNo
Please list any special dietary requirements or food allergies for medical reasons: NOTE: We will do our best to accommodate your food preferences but it is not always possible.
Do you have, or have you had, any of thefollowing diseases or problems?
If yes, to what?
Do you have any blood disorder such as anemia?YesNo
Are you taking any of the following? Please printthe drug name in the space provided.
Antibiotics or sulfa drugs YesNo
Are you allergic - have you reacted adversely to:
Do you have any condition or problem not listed above that you think we should know about? Please explain:
I am medically, physically and in all other respects, fit and fully able to participate in adventure travel and have no special medical requirements or conditions except as noted above. Should there be any change(s) related to my health or my ability to participate in the trip, I will notify the guides immediately. Before signing, please double check this document for accuracy, as it cannot be edited later.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Participant Medical and Personal Information Form
Agree & Sign