Backpack Across Patagonia's Tierra del Fuego, 2/24/2024 - 3/5/2024 SUPPLEMENTAL INFORMATION

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Participant Name Please enter your first and last name (e.g. John Smith).

Dietary Requirements Please describe your dietary requirements, specifying those which are medically necessary and those which are preferences.

Medical Conditions Please list and describe all medical conditions, recent injuries, and recent surgeries.

Allergies Please list all allergies including your level and severity of reaction.

Medications Please list all prescription and over-the-counter medications you are currently taking and their potential side effects.

International Medical Insurance Please list the company, policy number, and international contact phone number for your international medical insurance.

An International Medical Insurance Policy is an insurance policy that covers the costs of emergency medical treatment for an injury or illness that occurs during or as an immediate result of the trip. PLEASE BE SURE THAT YOUR MEDICAL INSURANCE POLICY ADEQUATELY COVERS TREATMENT COSTS OUTSIDE OF YOUR HOME STATE including covid-19 illness and the activities that you will be doing.

Emergency Evacuation Insurance Please list the company, policy number, and international contact phone number for your international emergency evacuation insurance.

An Emergency Evacuation Insurance Policy is an insurance policy which covers the costs of emergency evacuation from the trip itinerary to a place of medical treatment as the result of an injury or illness that occurs during the trip. The Mountaineers requires that this evacuation insurance includes a provision that the policy will get you home if the medical treatment lasts an extended time (most policies specify 7 days).

Trip Cancellation Insurance Please list the company, policy number, and international contact phone number for any Trip Cancellation insurance, and specify if it is a Cancel for Any Reason policy.

Participant acknowledgement of accuracy and understanding. By signing this form, I am declaring that, to the best of my knowledge, I have completed the questionnaire accurately. I also understand that by knowingly filling out the form inaccurately, or by withholding pertinent information about my health, I could cause serious harm to myself or others.. I agree to inform my trip leader should there be any changes to my health status prior to the start of the trip. I understand the outing may require vigorous activity that is both physically and mentally demanding in isolated areas without medical facilities. I am fully capable of participating on this trip.

Consent to share confidential information. By signing this form, I authorize the above medical information to be shared with volunteers, representatives, contractors or emergency medical personnel on occasion that emergency treatment is necessary.

Consent to accept aid. By signing this form, I am giving consent and permission for Mountaineers volunteers, representatives, or contractors to provide me with medical care, to transport me to a medical facility or to seek the aid of emergency medical services as deemed appropriate. I further authorize Mountaineers volunteers, representatives, or contractors to render whatever treatment they consider necessary for my health, and I agree to pay all costs associated with that care and transportation.

Participant Signature Please type your full legal name.

Date Signed

Participant Birth Date Enter the participant's date of birth. If participant is under 18, a parent or guardian must sign below.

Participant Email

Parent/Guardian Signature Please type your full legal name.

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Backpack Across Patagonia's Tierra del Fuego, 2/24/2024 - 3/5/2024 SUPPLEMENTAL INFORMATION

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