Emergency Medical Consent Form

Please fill out this form before you travel with us. It gives our trip leaders what they need to get you the right care quickly if something goes wrong.

1 Traveler information

Full legal name*

Date of birth*

Mobile phone*

Email*

Home address

Trip or workshop name*

Departure date

Return date

2 Emergency contacts

Choose people who are not traveling with you and can be reached by phone.

Primary contact

Name*

Relationship*

Phone*

Alternate phone optional

Secondary contact optional

Name

Relationship

Phone

3 Medical information

Share anything a doctor would need to know if you can’t speak for yourself. Write “None” where it applies.

Medical conditions*

Current medications and dosages*

Allergies*

Physical limitations or mobility concerns optional

Dietary restrictions optional

Blood type optional

Primary physician

Physician phone

4 Insurance

Health insurance provider*

Policy or member ID*

Travel insurance provider optional

Travel insurance policy number optional

Anything else we should know? optional

5 Consent and signature

I have read and agree to the statements above.*

Signature (type your full name)*

Date*