Medical & Traveler Profile

• Traveler's Name: *
• Occupation:
• Trip: *
• Other participants' names, if answering on behalf of them:

Part 1

Please explain all "yes" answers

1. Do you have diabetes, epilepsy, high blood pressure, heart disease, asthma or lung disease, ulcerative colitis or ulcers, any significant back, foot or leg problems, or any other diseases or conditions that could affect your participation on this trip? YesNo
   If yes, explain:
2. Have you been hospitalized in the past 2 years? YesNo
   If yes, explain:
3. Do you have any emotional or behavioral disorders (including phobias)? YesNo
   If yes, explain:
4. Do you take medication regularly? YesNo
   If yes, which ones and what for?
5. Do you have any allergies including allergic reactions to any drugs? YesNo
   If yes, which ones and what effect?

SWA would like to have your regular physician's telephone number as a contact in event of a medical emergency.

• Physician's Name:
• Physician's Phone Number:

Part 2

Outdoor Experience

Hiking

Camping

Biking

Houseback Riding:

• Any diet restrictions or food allergies? If vegetarian, please explain your needs (i.e. if you eat chicken or fish on occasion).
• Special interests - what leisure activities do you enjoy?
• Briefly describe relevant outdoor experience:
• Have you been to Latin America before? If so, where did you go?
• What are your expectations regarding this trip? Additional Comments?
• I hereby attest that, to the best of my knowledge, the above statements are true and accurate. By checking this box, I am signing voluntarily.
• Name: *
• Email Address: *
• Upon submitting this form, please wait until you get a “sent successfully” message. You will receive an automated email containing a copy for your records.

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