D2R Forms: MEDICAL

Phone: Cell/ Landline

Medical Emergency Contact Information / Main Contact Name

Relationship to Participant

Daytime / Evening Phone

Recent exposure to infectious deseases like Covid 19?

YES NO

if YES please explain

High Blood Pressure

YES NO

IF YES : Do you carry an inhaler?

YES NO

Heart Problems?

YES NO

Do you have any bone, joint, or muscle problems in any of the upper extremities?

Back Shoulders other

IF YES to any of the above, recent sprains, fractures, dislocations? explain

Do you have any problem with your hearing?

YES NO

IF YES please explain

Are you pregnant?

YES NO

Have you ever experiences altitude problems?

YES NO

IF YES please explain

Do you have, or have you ever had any significant illness requiring the regular care of a doctor?

YES NO

Dizziness, Fainting spells

YES NO

Emotional imparement or disability

YES NO

Immunizations current? Do you have the Covid 19 Vaccines? when?

YES NO

Epilepsy or convulsions?

YES NO

Allergies to drugs, insects, seasonal

YES NO

IS YES please list all allergies and if you bring an EPIPEN IN case you need one?

Tetanus : it is strongly advised that you are inoculated against this fatal disease and you obtain a booster within every 10 years. When was the last time you had a tetanus booster or inoculation?

Dietary Restrictions / Food Allergies (vegan,gluten free, peanuts,etc)

Additional Informations

Doctor's note attached

IF PARTICIPANT IS A MINOR, SIGNATURE OF PARENT OR GUARDIAN IS ALSO REQUIRED: In consideration of my minor child's being permitted to participate in the Trip, I accept and agree to the full contents of this agreement. I understand that I am responsible for and I accept the responsibility for the supervision throughout the duration of the Trip of any minor traveling in my care. I also agree to RELEASE, HOLD HARMLESS, INDEMNIFY AND DEFEND the Released Parties (defined in Section 3) from all liabilities and claims that arise in any way from any injury, death, loss or harm that occurs to my minor child during the Trip or in any way related to the Trip. This includes any claim of the minor and any claim arising from the negligence of the Released Parties. I understand that nothing in this agreement is intended to release claims for gross negligence, intentional or reckless misconduct, or any other liabilities that Virginia law does not permit to be excluded by agreement.

Mother/ Father/Guardian Name

If participant is over 75 at the date of the trip , we require your physician approval . Note that emergency medical facilities may not be available on the trip and physicians do not accompany our group. Make any qualifying comments in the space bellow

Signature of Physician

Name and Adress of Physician

Physical Examination / date of most recent Physical

PLEASE NOTIFY YOUR TRIP LEADER IMMEDIATELY IF ANY INFO ON THIS FORM CHANGES

I hereby certify that all the information i filled out on this medical form is true and correct to the best of my knowledge

D2R Medical Form Participant Information

Take the first step oF a lifelong adventure with d2r

This is your time! d2r

Copyright © D2R UNPLUG 2020-All rights reserved.