CONFIDENTIAL MEDICAL & EMERGENCY INFORMATION
(Print individually—one sheet per participant. Fill out and place in a sealed envelope or vehicle glovebox)
Trip Name / Destination: __________________________________________________
Trip Dates: ___________________________________________________________
INSTRUCTIONS: Filling out this form is completely voluntary but highly recommended for remote backcountry travel. This document is strictly confidential. Place the completed sheet in a sealed envelope with your name on it inside your vehicle glovebox. Trip organizers do not collect these envelopes. It will only be accessed or turned over to emergency personnel/first responders in the event of a medical emergency during a trip.
1. Participant Identification
- Full Legal Name: ______________________________________________________
- Date of Birth: ______________________
- Primary Phone Number: ________________________________________________
- Vehicle Info on Trip (Year, Make, Model, Color): _______________________
2. Primary Emergency Contacts
Contact 1 (Main):
- Name: ___________________________________________________________
- Relationship: ____________________________________________________
- Phone Number(s): _________________________________________________
Contact 2 (Alternative):
- Name: ___________________________________________________________
- Relationship: ____________________________________________________
- Phone Number(s): _________________________________________________
3. Medical Profile (For First Responders & Search & Rescue)
- Blood Type (If known): ___________
-
Severe Allergies (e.g., bee stings, penicillin, latex, specific foods):
___________________________________________________________________________
___________________________________________________________________________ -
Current Medications (Crucial for first responders, especially blood thinners, insulin, or heart medications):
___________________________________________________________________________
___________________________________________________________________________ -
Critical Medical Conditions / History (e.g., asthma, diabetes, epilepsy, cardiac history, severe joint issues):
___________________________________________________________________________
___________________________________________________________________________ -
Medical Devices (e.g., pacemaker, epi-pen in vehicle, inhaler):
___________________________________________________________________________
4. Health Insurance Information (Optional)
- Insurance Provider: ___________________________________________________
- Policy / Group Number: _______________________________________________
AUTHORIZATION FOR EMERGENCY RELEASE
By signing below, I certify that the information provided is accurate and voluntary. I authorize my trip mates to hand this document directly to emergency medical technicians, doctors, or Search and Rescue personnel if I am incapacitated or unable to communicate during the trip.
Participant Signature: _________________________________________
Date: ______________