As a participant in overnight trips, I am in physical, mental and emotional readiness for the rigors of the experience. As a participant in outdoor adventure sports, I realize that the fun of these sports holds certain hazards and inconveniences. I realize that I am dealing with the forces of nature and that I am dependent on myself alone to survive safely. I have adequately prepared and equipped myself for the challenges of such adventure. And deviation from equipment recommended by the trip leader is my decision, at my own risk.

    I hold harmless The Wilderness Center and the Backpacking Club, their officers, staff, and associates; the trip leaders; and fellow participants; from any physical, mental, or emotional injury which results from participating in a trip. I ask that all relatives, heirs, insurance carriers, and all others consider this document morally, if not legally, binding. I ask that they also hold harmless The Wilderness Center and the Backpacking Club officers, staff, associates; trip leaders; fellow participants; from any injury which results in participating in a trip.

    I agree that if the trip leader determines I am not prepared for the rigors of the trip, or that I am not properly equipped, then I will agree not to participate.

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    Signature                                                                    Date
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Backpackers' Personal Medical Information Card

Name:_________________________________________________________________(Please Print Legibly)

Address: _________________________________________________________________________________

City/State/Zip: ____________________________________________________________________________

Phone: ________________    Date of Birth:    ____________    Social Security #:____________________

In an emergency call: ______________________________________________    Phone: ________________

Address: ________________________________________________________________________________

City/State/Zip: ___________________________________     Relationship: ______________________

Physician name: _________________________________        Phone: ___________________________

City/State/Zip: __________________________________________________________________________

Health Insurance Carrier: ________________________________________________________________

Account or Group #:______________________________        Phone: ___________________________

Blood Type: ________________________ Date of last Tetanus Booster: ___________________________

Drug Allergies: __________________________________________________________________________

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Other Allergies (Bee sting, foods, etc.):_______________________________________________________

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List ALL medications currently taken & dosages: _____________________________________________

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Where are the medications in your pack? ____________________________________________________

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What appliances are you wearing: (Contacts, false teeth, hearing aid(s), pacemaker, prosthesis, etc):___

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Conditions a doctor should know about such as: diabetes, heart disease, high blood pressure, etc.______

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Signature: ____________________________________    Date: ________________________

Attach additional information as necessary. I certify this information is correct.