The Elemental Self Medical Form - THE ELEMENTAL SELF

Date*

Name of Program*

Name*

First Last

Preferred Pronouns

Gender Identification

Age*

Phone*

Sarah uses What's App to communicate with the group prior to the trip and for you all to coordinate logistics. Do you already use and have What's App?

Yes
No, I need to download it onto my phone (which I will do pronto!)

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email address*

For Emergency Use

Your Doctor’s Name*

Prefix Last

Doctor’s Phone*

Medical Insurance Co.*

Group/Policy No.*

In case of emergency, notify*

First Last

Relationship*

Cell Phone*

Does your doctor know you are going to participate on this trip?*

Yes
No

Does your emergency contact person know you will participate?*

Yes
No

Are you under the care of a physician?*

Yes
No

Are you seeing a therapist at present?*

Yes
No

Therapist Name

Prefix Last

Therapist Phone

Do you have any history of emotional or psychological challenges? (anxiety, depression, bi-polar, schizophrenia, eating disorder, alcohol/drug treatment or counseling, aggressive/violent behavior, suicidal thoughts/attempts, self-harming behaviors etc)?*

Yes
No

If yes, please describe

Please list any medications you are taking for psychological challenges

Have you ever been backpacking?*

Yes
No

Have you had a Traumatic experience of death or family/friend in past year?*

Yes
No

If yes, please describe

Do you wear a Medic-Alert Tag or any other marker of a medical problem?*

Yes
No

If yes, please describe

Were you hospitalized in the last two years?*

Yes
No

If yes, please describe

Please list and describe any past or present injuries. What makes these feel worse? What makes them feel better?

Have you ever had a heart attack of any kind, or been told by a doctor that you have high blood pressure, a heart murmur or heart disease?*

Yes
No

If yes, please describe

Have you ever experienced a seizure of any kind?*

Yes
No

If yes, please describe

Do you have allergic or anaphylactic reactions to any insults, such as environmental substances, foods, drugs, insect bites or stings?*

Yes
No

If yes, please describe

Do you carry an Epipen for any reason? If you do, please be aware that you must bring TWO FULL DOSES (2 pens) of your own prescription with you on this trip. The Elemental Self can administer Epipens, but does not carry our own supply.

Do you have Gastrointestinal disturbances?*

Yes
No

If yes, please describe

Do you have any dental issues that could potentially flare on this trip?

yes
no
I don't know

If yes, please describe. *Please bring any medication that might be needed to treat any current dental condition should it flare up. Dental issues can be a cause for evacuation if left untreated.

Do you have Urinary or reproductive tract complications, including yeast infections?*

Yes
No

If yes, please describe below. ** Please bring personal UTI/yeast infection medication on this trip. The Elemental Self does not carry (and is not authorized to carry) antibiotics. An untreated UTI /yeast infection can be cause for an evacuation, so please bring the medication you would need if an infection did arise.

Do you have hemophilia or any other disorder that impairs blood-clotting?*

Yes
No

If yes, please describe

Do you have a lung disease or any kind of breathing problem, including asthma?*

Yes
No

If yes, please describe

Do you have any muscle, joint, or bone related disabilities? (inlcuding knee, ankle and wrist injuries)*

Yes
No

If yes, please describe

Do you have Backaches, spinal injury, disc trouble?*

Yes
No

If yes, please describe.

Do you have night terrors or sleepwalk?*

Yes
No

If yes, please describe

Do you have trouble with headaches?*

Yes
No

If yes, please describe

Do you have any kidney disease?*

Yes
No

If yes, please describe

If you walked on the level for a mile at an average pace would you get out of breath, have pains in the chest, develop muscle fatigue or have pains in your legs?*

Yes
No

Describe your degree of fitness in your own words

Do you have hypoglycemia or diabetes?*

Yes
No

If yes, please describe. **Please note that you will be required to adequately monitor and self-manage medication on the trip and to bring ample supplies.

Do you have any other chronic or acute disease that, in any way, threatens your health?*

Yes
No

If yes, please describe

Are you taking any medication at the present time? Please include medical marijuana in this list.*

Yes
No

If yes, specify each drug, the dose and the reason for taking.

I agree to abstain from recreational substances for the full duration of our trip/trips.*

Yes I agree.

Is it ok to take personal pictures of you on this trip?*

Yes
No
It Depends

Is it ok for Sarah to share pictures taken on this trip (that include your face) with her email list and on social media, to share about the experience and let folks know about future trips?

Yes
No
It depends

Please share anything requests/boundaries you have about your pictures being taken and/or shared

Section Break

When was your last tetanus shot? (You can look up the exact date by looking up the vaccination record database of the state in which you got your last tetanus shot. It's a very easy search usually. Make your best to guess if you don't know. This is relevant if you cut yourself on something dirty or rusty on our trip.)*

This information is accurate and complete. I agree to cooperate with the trip guides an engage in this program with full consideration of my health history and health concerns. I give my permission to the The Elemental Self Guides guides on this trip to seek emergency medical diagnosis or treatment for me in the event that I am unconscious or unable to make my own decisions. Every trip has at least one guide with a Wilderness First Responder Certification who will treat injuries and medical issues in line with their training and scope of practice, which may include seeking transportation to the nearest medical facility, or contacting such a facility to arrange emergency transport.

Signature

LIABILITY WAIVER

The Elemental Self carries liability insurance for these trips and our policy requires this additional waiver.

DATES AND LOCATION OF YOUR SPECIFIC TRIP

BACKPACKING WARNING, ASSUMPTION of RISK, LIABILITY RELEASE, INDEMNITY and HOLD HARMLESS AGREEMENT

PLEASE READ CAREFULLY BEFORE SIGNING. THIS IS A RELEASE OF LIABILITY AND WAIVER OF CERTAIN LEGAL RIGHTS. The person who is backpacking in the region stated above shall be referred to hereinafter at “PARTICIPANT”. “THE UNDERSIGNED” means only the PARTICIPANT when the PARTICIPANT is age 18 or older OR it means both the PARTICIPANT and the PARTICIPANT’s parent or legal guardian when the PARTICIPANT is under the age of 18. THE UNDERSIGNED agree and understand that BACKPACKING (hereinafter the “ACTIVITY”) can be HAZARDOUS AND INVOLVES THE RISK OF PHYSICAL INJURY OR DEATH. THE UNDERSIGNED agree and understand that there are risks associated with strenuous physical exertion and with participating in the ACTIVITY and that falls, INJURIES AND/OR DEATH may result from engaging in the ACTIVITY. THE UNDERSIGNED agree and understand that risks include, but are not limited to: 1. Risk of injury from the activity and equipment utilized is significant including the potential for permanent disability and death. 2. Falling, causing broken bones severe injuries to the head, neck and back which may result in severe impairment or even death. 3. All "act of nature," including but not limited to avalanche, rock fall, inclement weather, thunder and lighting, severe and or varied wind, temperature and other weather conditions. 4. Risks associated with crossing, climbing or down-climbing of rock, snow and/or ice. 5. Risks associated with river crossings, fordings, or portaging. 6. Possible equipment failure and/or malfunction of my own or others' equipment, which may have been rented, borrowed, or personally owned. 7. My own negligence and/or the negligence of others, including employees, agents, independent contractors or representatives of including but not limited to operator failure. 8. Cold weather and heat related injuries and illness including but not limited to frostnip, frost bite, heat exhaustion, heat stroke, sunburn, hypothermia and dehydration. 9. Attack by or encounter with insects, reptiles, and/or animals. 10. Accidents or illness occurring in remote places where there are no available medical facilities. 11. Fatigue chill, and/or dizziness, which may diminish my/our reaction time and increase the risk of accident 12. My sense of balance, physical coordination, and ability to follow instructions. 13, The physical condition of the PARTICIPANT, dehydration, and high elevation. In consideration for allowing the PARTICIPANT to participate in the ACTIVITY, THE UNDERSIGNED hereby ASSUME ALL RISKS associated with the PARTICIPANT’s participation in the ACTIVITY. Additionally, THE UNDERSIGNED AGREE TO HOLD HARMLESS, RELEASE, DEFEND AND INDEMNIFY THE ELEMENTAL SELF, its affiliated organizations and companies, and each of their respective insurance carriers, agents, employees, representatives, assignees, officers, directors, and shareholders (each hereinafter a “RELEASED PARTY”) FOR ANY AND ALL LIABILITY and/or claims for injury or death to persons or damage to property arising from the PARTICIPANT’s participation in the ACTIVITY, including those claims based on any RELEASED PARTY’s alleged or actual NEGLIGENCE or BREACH OF any express or implied WARRANTY. THE UNDERSIGNED take full responsibility for any injury or loss to PARTICIPANT, including death, which PARTICIPANT may suffer, arising in whole or in part out of the ACTIVITY. By signing this release, THE UNDERSIGNED AGREE NOT TO SUE any RELEASED PARTY and agree they are releasing any right to make a claim or file a lawsuit against any RELEASED PARTY. THE UNDERSIGNED further AGREE TO DEFEND AND INDEMNIFY each RELEASED PARTY for any and all claims of THE UNDERSIGNED and/or a THIRD PARTY arising in whole or in part from the PARTICIPANT’s participation in the ACTIVITY. THE UNDERSIGNED agree to pay all costs and attorney’s fees incurred by any RELEASED PARTY in defending a claim or suit brought by or on behalf of THE UNDERSIGNED. THE UNDERSIGNED represent that the PARTICIPANT is in good health and there are no special problems associated with his/her care. THE UNDERSIGNED authorize any RELEASED PARTY and/or their authorized personnel to call for medical care for the PARTICIPANT or to transport the PARTICIPANT to a medical facility or hospital if, in the opinion of such personnel, medical attention is needed. THE UNDERSIGNED agree that upon the PARTICIPANT’s transport to any such medical facility or hospital that the RELEASED PARTY shall not have any further responsibility for the PARTICIPANT. Further, THE UNDERSIGNED agree to pay all costs associated with such medical care and related transportation provided for the PARTICIPANT and shall indemnify and hold harmless the RELEASED PARTY from any costs incurred therein, or any claims arising therefrom. By signing this release without a parent or guardian’s signature, the PARTICIPANT represents that he/she is at least 18 years of age, or, if signing as the parent or guardian of the PARTICIPANT, you represent that you are the legal parent or guardian of the minor PARTICIPANT. This release shall be binding to the fullest extent permitted by law. If any part of this release is deemed to be unenforceable, the remaining terms shall be an enforceable contract between the parties. This release shall be binding upon the assignees, subrogors, distributors, heirs, next of kin, executors and personal representatives of THE UNDERSIGNED. I HAVE CAREFULLY READ THE FOREGOING LIABILITY RELEASE, UNDERSTAND ITS CONTENTS, AND AM AWARE THAT I AM RELEASING CERTAIN LEGAL RIGHTS THAT I OTHERWISE MAY HAVE.

PRINTED NAME OF PARTICIPANT

My entry into this box below constitutes my electronic signature, and I agree to be legally bound by this document.

Date