MEDICAL & TRAVELER PROFILE

Please submit this form no later than 45 days prior to departure.

For your safety and that of your fellow travelers, good overall health and physical fitness are prerequisites for participating in any Grade III tour with Southwind Adventures. Participants should review our Trip Ratings and answer the questions below, listing any notable health conditions. Please refer to your Trip Itinerary to see the rating for your tour.
One form will suffice for couples & families if you note which aspects apply to each traveler.

Fields marked with a star (*) are required.

* Traveler's Name:

* Trip:

Occupation:

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?
 Yes No
If yes, explain:

2) Have you been hospitalized in the past 2 years?
 Yes No
If yes, explain:

3) Do you have any emotional or behavioral disorders (including phobias)?
 Yes No
If yes, explain:

4) Do you take medication regularly?
 Yes No
If yes, which ones and what for?

5) Do you have any allergies including allergic reactions to any drugs?
 Yes No
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 phone number:


Part 2

Outdoor Experience

Hiking:
 Basic Moderate Advanced

Camping:
 Basic Moderate Advanced

Biking:
 Basic Moderate Advanced

Horseback riding:
 Basic Moderate Advanced

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.