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Health and Fitness Form

To ensure that you have a safe and enjoyable kayaking experience, please complete the following information. Disclosures made on this form and all information are completely confidential.

Personal Information:

Multi-line address
Sex:
Male
Female
Other

Emergency Contact:

Outdoor Experience:

How often do you kayak?
Never kayaked
Once a year
Once a month
Once a week
Rate your swimming ability with 5 being the best.
Can not swim
1
2
3
4
5

General Health:

Please provide as much detail as possible in regards to any medical conditions of health or physical concerns that you have.

Do you have any personal concerns (e.g. fear of water, seasickness, physical limitations etc.)?
Yes
No
Any known allergies or sensitivities: (anaphylactic to bees, wasps, food, etc.)
Yes
No allergies
Do you wear glasses or use a hearing aid?
No
Glasses
Hearing aids
Both
Are you currently taking any medications?
Yes
No
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