PARTICIPANT MEDICAL FORM

WHY DO WE COLLECT THIS INFORMATION?

Participant medical history is kept on file in the event that we need to respond to an injury or emergency during your participation in the 40 Tribes program. All information will remain confidential and will only be shared with your guides and medical/evacuation professionals if needed.

Name *
Name
Date of birth *
Date of birth
Have you ever had any of the following? *
If yes, when is your expected due date?
If yes, when is your expected due date?
Emergency contact name *
Emergency contact name
Emergency contact phone *
Emergency contact phone
2nd Emergency contact name (optional)
2nd Emergency contact name (optional)
2nd Emergency contact phone (optional)
2nd Emergency contact phone (optional)
The information I have provided above is true, complete and correct (please check box). *
Date *
Date