MED Forms

CKAPCO / Antietam Creek, Greg Mallet-Prevost
Class/trip Registration and Information Form

1. Class/trip description and Date(s)_______________________________

Name ____________________________________ Date of Birth ___________________

Address ______________________________________________________________________

Street City State ZIP

Telephone number(s) ____________________________________________________________

Home Work Other

E-mail addresses) ______________________________________________________________ Home Work

Background

I am taking this course because____________________________________________

Briefly describe your paddling experience: _____________________________________________

____________________________________________________________________________

Approximate height and weight _____________________________________

____________________________________________________________________________

Please rate your swimming ability: none weak good strong

Confidential Medical and Emergency Information

Emergency contact ___________________________________________________

Name

____________________________________________________________________________

Telephone Number Relationship to you

Please list any medications you are taking: _____________________________________________

Do you have any medical conditions we need to know in case of emergency? ____________________

If so, please explain: _____________________________________________________________

Please indicate any medical or environmental allergies: ____________________________________

Do you have any physical limitations that could affect your participation in the course? ______________

If so, please explain: _____________________________________________________________

Signature and date please.