Health & History — TWP Tours Site

The information provided below will help TWP Tours staff keep you healthy and safe in the field. TWP Tours does not discriminate on the basis of physical limitations or disabilities. All of the information provided on this form will remain completely confidential.

For more information contact Daniela Bueso at daniela@twp.tours or call (970) 233-2396

Name *

First Name

Last Name

Birth Date

YYYY

Please describe any major hospitalizations or surgeries below. *

Have you been hospitalized within the past year? *

Yes

If yes, please describe below.

Strength of Swimming Ability

Do you consent to being administered over-the-counter medications (NSAIDS, Pepto-Bismol, Tums, etc.) by a TWP Tours staff member on program? *

Yes

Do you have any allergies? If yes please describe below. *

Do you have any anaphylactic allergies that require you to carry an Epi-Pen? *

Yes

Please describe any dietary restrictions or strong preferences.

Do you take any prescription medications? *

Yes

If yes, please list your prescriptions below.

Do you have any past or current physical or psychological condition that might prevent your safe participation in tour activities, or which may present a danger to yourself or others while on tour? *

Yes

If yes, please describe.

All information provided in this form is accurate at time of submission and I agree to update TWP Tours staff should any of the information I provided in this form change or evolve between now and the date of departure for my TWP Tours program. *

Yes

Signature *

Date

YYYY

Thank you!

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633 Remington Street
Fort Collins, CO 80524

970-484-3678

Email Address

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Thank you!