Traveler Name :
Traveler Date of Birth :
Parent / Guardian Name:
Traveler Date of Birth :
Parent / Guardian Name:
Brief Medical History
- Does the participant have a history of any medical conditions that affect the applicant’s ability to travel or participate in planned activities, including any vigorous activity?
- Is the participant currently receiving any medication or medical treatment?
- If the participant is under 18 years of age, do they require any supervised medication or medical attention?
- Please identify allergies including allergies to food, medications, and drug reactions
- Does the participant have a history of any emotional or behavioral disorder, such as depression, anxiety, anger, ADHD, and/or any other condition that may impact this experience?
- Are there any additional relevant medical information we should be aware of in order to ensure an excellent experience?
By signing this form, I (we) hereby authorize Ark Explore, It’s Officers, Representatives, Employees & Agents, in the case of any illness or medical emergency to consent to necessary medical care and treatment for me should I be unable to make a decision.
Traveler Name :
Traveler Date of Birth :
Parent / Guardian Name :