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1528 E. Montgomery Ave, Philadelphia, PA 19125

215-543-6171 | Info@ValleyToSummit.com

 

PARTICIPANT HEALTH FORM

In the interest of the personal safety of both the participant and the other trip members, please consider the questions carefully when completing the health form. A “Yes” answer does not automatically cancel a participant’s participation. If we have any question on the participant’s capacity to successfully complete the trip, we will call the participant to discuss it. Moreover, Valley to Summit, LLC (“VTS”) reserves the right to condition your participation in any trip upon the receipt of a written medical clearance from your family physician.

The participant is not accepted on the trip until the Health Form has been reviewed and approved by VTS personnel, and the participant has completed and returned all other required forms and payment.

Your detailed comments will expedite our review of this form.

Please check YES or NO for each item. Each Question must be answered and please provide date(s) and details for all “YES” answers.


Please select who will be participating...
AdultMinor
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First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Medical Information

General Medical Background

Does the participant currently have or have a history of:


1. Respiratory illness?*
No
Yes
2. Bronchitis?*
No
Yes
3. Pneumonia?*
No
Yes
4. Asthma?*
No
Yes
*Is the Asthma controlled with an inhaler?*
No
Yes

If yes, please bring one or more metered dose inhaler(s) with you on the trip and an aerochamber/spacer is recommended.

Please list triggers, last episode and hospitalizations?

5. Diabetes?*
No
Yes

If yes, please list whether Type I or Type II and please list associated conditions such as neuropathy or retinopathy:

6. Bleeding, clotting or other blood disorders, such as DVT (deep vein thrombosis)?*
No
Yes
7. Hepatitis or other liver disease?*
No
Yes
8. Neurological problems? Epilepsy?*
No
Yes
9. Seizures?*
No
Yes
10. Strokes*
No
Yes
11. Dizziness or fainting episodes?*
No
Yes
12. Migraines? Medications, frequency, are they debilitating?*
No
Yes

8-12. Describe frequency, date of last episode, and severity:


13. Cancer*
No
Yes

If yes, please provide cancer type, stage and treatment:

14. Gout*
No
Yes

If yes, please provide treatment:

15. Disorders of the Urinary tract, including kidney stones?*
No
Yes
16. Any disease?*
No
Yes

Questions 17 and 18 are for female applicants only


17. Treatment or medication for menstrual cramps?*
No
Yes
18. Are you pregnant?*
No
Yes

Cardiac History:

19. Any history of cardiac illness or significant risk factors, such as known coronary artery disease, hypertension, diabetes, family history of early cardiac death (<50 years old), hyperlipidemia, angina, tachycardia, bradycardia, or unexplained chest pain?*
No
Yes

Depending on the participant's history, risk factors and age, a ECG/EKG and/or stress test, waiver or medical clearance from applicant's cardiologist may be required.



Cold, Heat Altitude:

20. History of frostbite or Raynaud's Syndrome?*
No
Yes
21. History of heat stroke or other heat related illness?*
No
Yes

Muscle/Skeletal Injuries/Fractures:

Does the participant currently have or does he/she have a history within the past 3 years of:


22. Knee, hip or ankle injuries (including sprains) and/or surgery?*
No
Yes

Type of injury or surgery? When did the injury or surgery occur?

Is there full range of motion? Full strength?*
No
Yes

What is the most rigorous activity participated in since the injury/surgery? Results?

23. Shoulder, arm or back injuries (including sprains) and/or surgery?*
No
Yes

Type of injury or surgery? When did the injury or surgery occur?

Is there full range of motion? Full strength?*
No
Yes

What is the most rigorous activity participated in since the injury/surgery? Results?

24. Any other joint problems, such as arthritis?*
No
Yes

If yes, please provide details:

25. Head injury? Loss of consciousness? For how long?*
No
Yes
26. Does the participant have any physical, cognitive, sensory, or emotional condition that would require a special training/instruction environment?*
No
Yes

Personal History/Mental Health (Counseling/Psychiatric/Learning Disabilities):

Participants with a history of psychotherapy that required medication or has included hospitalization or residential treatment needs to be in a period of stability ranging from six months to two years, depending on the condition, before they can participate in a trip. Participants need to be gainfully occupied such as attending school or employed. Valley to Summit, LLC's trips are not appropriate for participants just leaving residential treatment facilities.


27. Has the participant had a treatment, counseling, psychotherapy or hospitalization with a mental health professional?*
No
Yes
28. Is the participant currently in treatment, counseling, psychotherapy or hospitalization with a mental health professional?*
No
Yes
29. Reasons for treatment or counseling? *
None
Suicide
Substance abuse/chemical dependency
Eating disorder (anorexia/bulimia)
Academic/career
ADD/ ADHD
Family issues/ divorce
Depression
Other

Please provide specific dates and details of counseling and psychotherapy history and medications that were prescribed:

30. Name, address and phone number of psychotherapist?


Allergies

31. Do you have any allergies related to any medications, foods, environmental or any other kind of allergy?*
No
Yes

If yes, please describe:

32. Has the participant had any systemic allergic reactions to insect bites, or bee/wasp stings or medications or foods involving hives, swelling of face/lips/neck or difficulty breathing?*
No
Yes

If appropriate, please bring a personal supply (2-3) of epinephrine, preferably in a pre-loaded auto injector (Epi Pens or Twinjets), and know how to use it.


33. Any other allergies, including allergies to medications?*
No
Yes

If yes, please provide details:

Medications:

34. Does participant plan to take any prescription or non-prescription medication on the trip?*
No
Yes

VTS groups travel in remote areas where access to medical care may be hours or days away.  Participants must understand the use of any prescription medications they may be taking. Written specific instructions are necessary. All participants who are required by their personal physician, psychiatrist or health care provider to take prescription medications on a regular basis must be able to do so on their own and without additional supervision.

Please provide a list of Medication, Dosage, Side Effects/Restrictions, Prescribing Doctor, and the Conditions for which the medication is being prescribed.

If Medication or Condition Changes Prior to the start of the Trip, Please Inform VTS as soon as possible.

Fitness (please provide details concerning the participant's exercise regime):


35. Does the participant exercise regularly?*
No
Yes

Please describe: 1) Activities; 2) Frequency; 3) Duration/Distance; and 4) Intensity Level (easy, moderate, competitive)

36. Does the applicant smoke? If so, how much?*
No
Yes

If so, how much:

37. Is the applicant overweight? Underweight? If so, how much?*
No
Yes

If so, how much:

38. Swimming ability:
Non-swimmer
Recreational
Competitive

By my signature, I the above-named Participant, attest that the information in this form is correct to the best of my information, knowledge and belief and that I had an opportunity to consult with my physician in regards to completing this form. I further agree that an electronically signed photocopy of this Agreement, or a record of this Agreement sent and received by facsimile, email or other electronic transmission, shall be enforceable and shall have full legal effect as an original.


First Participant's Signature*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive trip information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Medical Information

General Medical Background

Does the participant currently have or have a history of:


1. Respiratory illness?*
No
Yes
2. Bronchitis?*
No
Yes
3. Pneumonia?*
No
Yes
4. Asthma?*
No
Yes
*Is the Asthma controlled with an inhaler?*
No
Yes

If yes, please bring one or more metered dose inhaler(s) with you on the trip and an aerochamber/spacer is recommended.

Please list triggers, last episode and hospitalizations?

5. Diabetes?*
No
Yes

If yes, please list whether Type I or Type II and please list associated conditions such as neuropathy or retinopathy:

6. Bleeding, clotting or other blood disorders, such as DVT (deep vein thrombosis)?*
No
Yes
7. Hepatitis or other liver disease?*
No
Yes
8. Neurological problems? Epilepsy?*
No
Yes
9. Seizures?*
No
Yes
10. Strokes*
No
Yes
11. Dizziness or fainting episodes?*
No
Yes
12. Migraines? Medications, frequency, are they debilitating?*
No
Yes

8-12. Describe frequency, date of last episode, and severity:


13. Cancer*
No
Yes

If yes, please provide cancer type, stage and treatment:

14. Gout*
No
Yes

If yes, please provide treatment:

15. Disorders of the Urinary tract, including kidney stones?*
No
Yes
16. Any disease?*
No
Yes

Questions 17 and 18 are for female applicants only


17. Treatment or medication for menstrual cramps?*
No
Yes
18. Are you pregnant?*
No
Yes

Cardiac History:

19. Any history of cardiac illness or significant risk factors, such as known coronary artery disease, hypertension, diabetes, family history of early cardiac death (<50 years old), hyperlipidemia, angina, tachycardia, bradycardia, or unexplained chest pain?*
No
Yes

Depending on the participant's history, risk factors and age, a ECG/EKG and/or stress test, waiver or medical clearance from applicant's cardiologist may be required.



Cold, Heat Altitude:

20. History of frostbite or Raynaud's Syndrome?*
No
Yes
21. History of heat stroke or other heat related illness?*
No
Yes

Muscle/Skeletal Injuries/Fractures:

Does the participant currently have or does he/she have a history within the past 3 years of:


22. Knee, hip or ankle injuries (including sprains) and/or surgery?*
No
Yes

Type of injury or surgery? When did the injury or surgery occur?

Is there full range of motion? Full strength?*
No
Yes

What is the most rigorous activity participated in since the injury/surgery? Results?

23. Shoulder, arm or back injuries (including sprains) and/or surgery?*
No
Yes

Type of injury or surgery? When did the injury or surgery occur?

Is there full range of motion? Full strength?*
No
Yes

What is the most rigorous activity participated in since the injury/surgery? Results?

24. Any other joint problems, such as arthritis?*
No
Yes

If yes, please provide details:

25. Head injury? Loss of consciousness? For how long?*
No
Yes
26. Does the participant have any physical, cognitive, sensory, or emotional condition that would require a special training/instruction environment?*
No
Yes

Personal History/Mental Health (Counseling/Psychiatric/Learning Disabilities):

Participants with a history of psychotherapy that required medication or has included hospitalization or residential treatment needs to be in a period of stability ranging from six months to two years, depending on the condition, before they can participate in a trip. Participants need to be gainfully occupied such as attending school or employed. Valley to Summit, LLC's trips are not appropriate for participants just leaving residential treatment facilities.


27. Has the participant had a treatment, counseling, psychotherapy or hospitalization with a mental health professional?*
No
Yes
28. Is the participant currently in treatment, counseling, psychotherapy or hospitalization with a mental health professional?*
No
Yes
29. Reasons for treatment or counseling? *
None
Suicide
Substance abuse/chemical dependency
Eating disorder (anorexia/bulimia)
Academic/career
ADD/ ADHD
Family issues/ divorce
Depression
Other

Please provide specific dates and details of counseling and psychotherapy history and medications that were prescribed:

30. Name, address and phone number of psychotherapist?


Allergies

31. Do you have any allergies related to any medications, foods, environmental or any other kind of allergy?*
No
Yes

If yes, please describe:

32. Has the participant had any systemic allergic reactions to insect bites, or bee/wasp stings or medications or foods involving hives, swelling of face/lips/neck or difficulty breathing?*
No
Yes

If appropriate, please bring a personal supply (2-3) of epinephrine, preferably in a pre-loaded auto injector (Epi Pens or Twinjets), and know how to use it.


33. Any other allergies, including allergies to medications?*
No
Yes

If yes, please provide details:

Medications:

34. Does participant plan to take any prescription or non-prescription medication on the trip?*
No
Yes

VTS groups travel in remote areas where access to medical care may be hours or days away.  Participants must understand the use of any prescription medications they may be taking. Written specific instructions are necessary. All participants who are required by their personal physician, psychiatrist or health care provider to take prescription medications on a regular basis must be able to do so on their own and without additional supervision.

Please provide a list of Medication, Dosage, Side Effects/Restrictions, Prescribing Doctor, and the Conditions for which the medication is being prescribed.

If Medication or Condition Changes Prior to the start of the Trip, Please Inform VTS as soon as possible.

Fitness (please provide details concerning the participant's exercise regime):


35. Does the participant exercise regularly?*
No
Yes

Please describe: 1) Activities; 2) Frequency; 3) Duration/Distance; and 4) Intensity Level (easy, moderate, competitive)

36. Does the applicant smoke? If so, how much?*
No
Yes

If so, how much:

37. Is the applicant overweight? Underweight? If so, how much?*
No
Yes

If so, how much:

38. Swimming ability:
Non-swimmer
Recreational
Competitive

By my signature, I the above-named Participant, attest that the information in this form is correct to the best of my information, knowledge and belief and that I had an opportunity to consult with my physician in regards to completing this form. I further agree that an electronically signed photocopy of this Agreement, or a record of this Agreement sent and received by facsimile, email or other electronic transmission, shall be enforceable and shall have full legal effect as an original.


Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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