This form must be filled out and signed before you begin hiking. It is our responsibility to ensure we are aware of any mitigating health conditions and have the authority to act upon any of your injuries should an emergency arise..

 

To All Fitpacking Participants:

THE FOLLOWING IS A LEGAL DOCUMENT. Please read it carefully and make sure you understand it before signing. If you have any questions, please consult an attorney. Please understand that you will not be allowed to participate in the trip if you do not sign this agreement or if there are any changes to this agreement.

 

Disclosure Section

This first part of the Fitpacking Participation Form is the Disclosure Section. In this Section, “we” and ”us” means Fitpacking, and “you” means the participant. In this Section, Fitpacking provides the participant with important information about some of the potential dangers of the trip.

 

We at Fitpacking want you to have an enjoyable backpacking experience. However, we also want to make sure you are physically capable of taking this trip. To keep you safe, we need to know of any medical or health conditions that would affect our ability to keep you healthy in the event of a medical emergency, injury, illness, allergy, disease or accident.

 

Prior Conditions

I certify that I am generally in good physical condition. I do not have any medical or physical condition that would affect my ability to meet the physical demands of this trip. I do not regularly take (or keep available in case of emergency) prescription or over-the-counter medications except the following:

 

___________________________________________________________________

(list medications or write "none")

 

I understand that I am responsible for bringing adequate supplies of medications. I understand that certain medications require controlled environments, such as refrigeration or storage between a specified range of temperatures, and that it may not be practical to maintain medications in such controlled conditions during the trip. I agree that I am responsible for making alternative arrangements with respect to any medications that I may need.

 

I am allergic to the following:

 

___________________________________________________________________

 

___________________________________________________________________

(list foods, plants, medications and severity or write "none")

 

Continued...

I have adequate health, disability and life insurance, and I acknowledge that Fitpacking does not provide accident or medical insurance. Prior to departing on the trip, I will provide Fitpacking with legible copies of both sides of my medical insurance card for use in an emergency when I am unable to produce them to medical facilities.

 

I hereby give permission for transportation to any medical facility or hospital, and I authorize any guide, any other participant or any available medical personnel to render emergency medical care to me as they may deem necessary or appropriate. I agree to pay for all costs and expenses associated with any medical care I may receive, including, if necessary, the cost of evacuation. I hereby authorize the release of any medical information, including information concerning my HIV or "AIDS" status, in the possession of Fitpacking to any medical facility, hospital, ambulance, first aid provider, first aid service, doctor, nurse or other such person rendering care of my behalf. I hereby waive any action or claim against Fitpacking or any health care provider, hospital, doctor, nurse or first aid provider for the release of this medical information.

 

I hereby authorize that Fitpacking may use and disclose (individually or as part of an aggregate measure) medical information gathered from or about me before, during or after the trip relating the impact of the trip on my health, including, without limitation, information relating to my weight, measurements and body composition.

 

I understand that Fitpacking makes no representations or warranties of any kind, express or implied, regarding the impact of this trip on my health. including, without limitation, no representation or warranty that I will lose weight or improve my body composition.

 

I have read this Medical Form carefully. I understand it, and I agree to be bound by it.

 

___________________________________________________________________________________________

Participant Name (print)

 

___________________________________________________________________________________________

Address

 

___________________________________________________________________________________________

Phone / Email

 

___________________________________________________________________________________________

Name / Phone of Contact person in case of emergency

 

___________________________________________________________________________________________

SIGNATURE