Medical-Contact Information

The information you provide on this form will be kept strictly confidential and will only be used by employees or the principal of Colwest Alpine Adventures and/or rescue/medical personnel in the event of an emergency.

Medical-Contact

Students will need to complete and submit this medical-contact form at least a week prior to the first field day of your AST course.

Name(Required)

First Last

Phone(Required)

Email(Required)

Allergies(Required)

Please list any allergies you have

Disabilities or illnesses(Required)

Describe any chronic disabilities or illness you have (e.g. heart condition, high blood pressure, epilepsy, diabetes, asthma etc.):

Medications(Required)

Are you on any medications, and if so, what medication and for what condition?

Physical Limitations(Required)

Do you have any physical limitations? (e.g. previously injured knee, spinal column, or other limitations)

Your Emergency Contact Info(Required)

In case of emergency, who do we contact? Name: Relationship: Best Phone:

Companion Rescue Equipment(Required)

Do you need to borrow any of the following Avalanche Transceiver: Avalanche Probe: Avalanche Shovel: Snow Saw:

Transceiver

Probe

Shovel

Saw