Expedition Guide Medical Clearance Form
Please complete this form to confirm your medical fitness and acknowledge risks before participating as an expedition guide.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any chronic medical conditions?
*
No
Yes (please specify)
List any allergies (including medication, food, or environmental):
*
Are you currently taking any medications? If yes, please list them.
*
Have you experienced any illness or injury in the past 12 months that could affect your participation?
*
No
Yes (please specify)
Physician’s Name (if applicable)
Please provide any additional medical information relevant to your participation as an expedition guide.
I confirm that I am physically fit to serve as an expedition guide and will notify organizers of any changes to my health status.
*
Yes, I confirm
No
Signature (please sign below to confirm the above information is accurate and that you accept the terms and risks outlined)
*
Submit Medical Clearance
Submit Medical Clearance
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