Backcountry EMERGENCY BACKCOUNTRY

Trip Planner SEARCH & RESCUE REPORT

FILL THIS OUT AND LEAVE IT To Report a Forest Fire, Lost
WITH SOMEONE BEFORE YOU Person, Illness, Injury or
LEAVE HOME! other emergency call:

1. Where am I going?
FOREST RANGER
Nearest Town: _____________________ DISPATCH
518-891-0235
Name of the Road or Route # that the trailhead
is on: ______________________ Name: ___________________ Lost
Injured
__________________________________ Age: ________ Sex:______ Weight:___________
Backcountry Destination:
__________________________________ Place Last Seen: ___________________________

__________________________________ _________________________________________
2. Who am I going with? (provide map if possible)
Total Number of People: _____________
Names of trip participants including yourself: Date, Day & Time Last seen:____/____/____
______________________________________
______________________________________ Day:_____________ Time:_________ AM PM
______________________________________
______________________________________ Next of Kin: _____________________________
The Leader is: __________________________
Telephone #: _____________________________
3. When will we be home?
We expect to be home on: _______________ Medical History:___________________________
(Day of the week)
_________________________________________
Date: ____/____/____ Time:________ AM PM
On Medication? YES NO
We expect you to call the Forest Ranger
Dispatch number listed below if we are not What kind of medications?___________________
home by:
________________________________________
Date: ____/____/____ Time:________ AM PM
Mechanism of injury: Type of Injury:
4. What Vehicle are we traveling in?
The vehicle we are traveling in is a: ___ Fall from height ___ Unconscious
Make and Model:_______________________ (above 10 feet) ___ Seizure
___ High speed crash ___ Simple Sprain
Color:____________ Year: _____________ (skiing, sliding on ___Chest Pain
ice, etc) ___ Apparent Fracture
License: _______________ ___ Slow fall while hik- ___ Excessive Bleeding
ing ___ Head Injury
I will call if I am late or if I change ___ Excessive heat or ___ Internal Injury
my plans. cold
___Sudden unexplained
Illness
IN CASE OF EMERGENCY OR IF I AM
NOT BACK HOME BY THE TIME Plan of Action:____________________________
INDICATED PLEASE CALL: __________________________________
518-891-0235 Trip Leader:_______________________________