Big Banana Adventures

Big Banana Adventures

Medical Release Form

In order to best accommodate your needs in the case of an emergency; please provide us with the following information. It will remain confidential, and will not exclude you from our adventures.

NAME:_________________________

TRIP DATE & DESTINATION:__________________

ADDRESS, CITY, POSTAL CODE: ______________________________________________

PHONE:_____________________

DATE OF BIRTH: ________

CITIZENSHIP: Guests need to provide this so we can register your trip with the Loreto Port Captain): ___________

IN THE CASE OF AN EMERGENCY, WE SHOULD CONTACT:

Name:___________________________________ phone:_____________

Relationship:______________________________

PLEASE LIST ANY MEDICATION YOU MUST TAKE: _______________________________________________________

Please investigate with your doctor whether your medication (A) requires special protection from sunlight or moisture, and (B) may create side effects specific to the wilderness (e.g. susceptibility to sunburn), and if your medication is life-sustaining (C) please bring a second set of your medication for our guides to carry. Your medication - any pills of any type - should be clearly labeled, including the dosage, and each type of pill carried in its own container.

PLEASE SPECIFY THE FOLLOWING:

PSYCHOLOGICAL LIMITATIONS (e.g. fear of water, heights): ________________________________________________

PHYSICAL LIMITATIONS (e.g. swimming ability): ___________________________________________________________

CHRONIC ILLNESS (e.g. DIABETES, ANGINA): ___________________________________

PRIOR HISTORY OF JOINT INJURY (e.g. tendonitis, shoulder separation, carpal tunnel): ___________________________

ALLERGIES TO FOOD OR MEDICATION: _________________________________________________________________

(if your allergy is anaphylactic, or life threatening, please specify, and bring an Ana Kit)

WHAT FOOD ITEMS WILL YOU NOT EAT? _________________________________________________

DATE OF LAST TETANUS IMMUNIZATION: __________ If you have not had a tetanus booster in the past 10 years, even a small cut may force an evacuation, at your own cost.

DO YOU WEAR CONTACTS? _______

I understand that withholding information may contribute to injury or illness complications, and possibly compromise the care provided in the event of an emergency. If any of the above changes prior to, or during, the trip I will notify the guides.

(Signature) _________________________

DATE__________

Please submit to our office at least 30 days before trip start.