TREKERS NAME_________________________________

Emergency Contact Information: Please provide two different names and numbers.
1) Name:__________________ Phone_____________________ Relationship______________________
2) Name:__________________ Phone_____________________ Relationship______________________

Food Concerns:
YES NO

Condition
Celiac/Gluten
Lactose Intolerance
Vegetarian/Vegan

Condition
Diabetic needing to count carbohydrates
Critical food allergies
Nut Allergy

YES

NO

Please explain any food allergies/conditions and/or other food-related concerns:

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Health Concerns: Please check and explain any physical or emotional health concerns. All youth must be selfcare to attend trek. We will not supply epi pens.
Condition
ADHD/ADD
Anxiety:
Depression:
Mental Health Disorder:
Seizures:
Diabetes

Condition
None Mild Moderate Severe
Asthma:
None Mild Moderate Severe
None Mild Moderate Severe
Hay Fever:
None Mild Moderate Severe
None Mild Moderate Severe
Heart Condition:
None Mild Moderate Severe
None Mild Moderate Severe
Physical Limitations :
None Mild Moderate Severe
None Mild Moderate Severe
Special Equipment needs None Mild Moderate Severe
No
Yes
If yes, please check: Pump Injections

Please explain any of the health concerns marked above, as well as any other health concerns not indicate
above (attach additional sheet if necessary)
OTC Medication Permission:
I grant permission for leaders to administer
the following if needed:

Medication
Ibuprofen
Tylenol
Decongestant
Antihistamine
Antacid

YES

Other Known Allergies (latex, medications, insects, etc.)

__________________________________________
__________________________________________
__________________________________________
Long-term Prescription Medications:
__________________________________________
__________________________________________
__________________________________________
Please list any meds that will likely be taken on trek. All
prescription meds must be in the original container with
dosage instructions clearly legible.

Insurance Information: Do you have health insurance: Yes

No
Name of Insurance Company and Plan: __________________________________________________________
ID#____________________________________
Group# ____________________________________