Medical Form

360 Guiding

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Medical Info

Please complete for each member of your group

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Are you responsible for your group? *

Number of participants in your group *

Number of participants in your group, including yourself.

Emergency Contact Person: *

First

Last

Emergency Contact Phone Number *

Your Doctor / Hospital *

First

Last

Doctor's Phone Number *

Medical Insurance Provider *

Insurance ID Number *

Your Age *

Height *

Weight *

Shoe Size *

For Microspikes or Snowshoes

Do you have any ALLERGIES? *

YES NO NOT SURE

If yes, allergic to what? (Foods, Medications, Bees, etc. – Please be specific) *

Do you carry an Epi-Pen? *

YES NO

If yes, what is the Epi-Pen for? Please remember to bring your Epi-Pen with you, and an extra if you have it. *

Do you carry an asthma inhaler? *

YES NO

If yes, for what type of asthma, and when was your last attack? *

Do you take or carry any other medications? *

YES NO

If yes, what other med(s) and for what? *

Desired activity level: *

What is your fitness level? *

Please describe any past heat or cold injuries: *

Please describe any dietary restrictions: *

Please describe any exercise-induced illnesses or loss of consciousness: *

Comments, requests or special needs: *

May we share photos of you during your activity on social media, our website, advertising, and/or in our literature? *

I understand the risks associated with this activity, and that I will have to sign a release of liability waiver before participating. *

I Agree

Submit

[email protected]
Call or Text (914) 362-8413

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First Name

Email Address

Home
Day Hikes
Backpacking & Camping Trips
Booking & Trip Info

Medical Info

Please complete for each member of your group

[email protected]Call or Text (914) 362-8413

Subscribe to our newsletter - Be the first to hear about new trips and exclusive offers.

[email protected]
Call or Text (914) 362-8413