This health statement is confidential. It is designed to give the trip leaders a better picture of who you are so that we can better prepare for and serve your individual needs. In the event of an injury this statement will be the most important information we have about your medical history, so please be as thorough as possible. THANKS!
General Information
Full Name
If you have a preferred name, please place in parenthesis after your birth name. Example: Johnathan Doe (John Doe)
Your answer
CID #
Write "N/A" if not applicable.
Your answer
Local Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Height
Example: 5' 11" or 180.34 cm
Your answer
Weight
Example: 175 lbs or 79.38 Kilograms
Your answer
Birthdate
MM
/
DD
/
YYYY
Age
Your answer
Cell Phone Number
Your answer
Email Address
Your answer
Activity Level
Do you smoke?
Do you wear corrective lenses?
Can you swim?
Your general activity level is...
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