Personal Information

BIG ROCK OUTFITTERS PERSONAL INFORMATION SHEET

Fill out completely and email to service@bigrockoutfitters.com  ASAP. Please print.

Name ____________________________________Nickname_______________________

Home address_____________________City__________________State_______Zip_____

Home phone(_____)_________Cell phone(_____)_________E-mail__________________

Height________Weight_______Age______Sex_____Occupation_____________________

 Emergency Contact______________________  Relationship_______________________

Phone(_____)________

OUTDOOR EXPERIENCE

 Have you backpacked before, and if so, how recently? ____________________________ ________________________________________________________________________

Have you canoed before on a lake or river, and if so, how often?_____________________ ________________________________________________________________________

Can you perform the following in a canoe? Circle any you know: draw, pry, eddy turn, bow rudder, ferry

 Circle your swimmer type: strong, moderate, weak.    Can you swim 100 yards? _______

 Do you exercise? ________ If yes, describe below:

Type of exercise                                                   Frequency and length of time

 1.____________________________            _______________________________

 2.____________________________            _______________________________

MEDICAL INFORMATION

Do you have any allergies to: (bee stings, specific foods, iodine, medicine, etc?____

If yes, do you have an Epi-Pen? _______

Type of allergies: _______________________________________________________ _____________________________________________________________________

Do you have any physical/mental  condition or medical history such as asthma, diabetes, seizures, bipolar disorder, ADD, hypertension,  heart trouble, back, knee or other joint injury that might be a concern on the trip? ____

 If yes, please describe:__________________________________________________ _____________________________________________________________________ _____________________________________________________________________

 Are you on any medications? ___________ If so, list the name, dosage and frequency for each.___________________________________________________________________ ________________________________________________________________________