Earth Team Participant Health Form

Personal Information












In Case of an Emergency, please contact:







Medical Insurance Information(if applicable): 




Medical History:



















Do you have any psychiatric and/or mental health conditions? Please circle either YES or  NO. If  YES, please explain below.
Yes No

Do you have any medical conditions? Please circle either YES or  NO. If  YES, please explain below.
Yes No


Medical Release:

I understand that participation in this program  may present possible risks and hazards including, but not limited to hiking on and off the trail, travel in vans and travel in remote areas with limited access to emergency transportation, medical facilities, and personnel, or means of rapid evacuation. I assume any and all risks and dangers in conjunction with this trip and release Earth Team, or its authorized representatives, from all responsibility for damages, injuries, losses,  delaysdue  to  any  reason  whatsoever,  including  but  not  limited  to  the  voluntary  rendering  in  good  faith  of emergency  medical  assistance.  In  the  event  of  need,  I  hereby  grant  permission  of  Earth  Team  or  its  authorized representatives to arrange for such evacuation and medical care as I may require. In the event of serious illness or the need for hospitalization and or major surgery, Earth Team will use all reasonable efforts to contact the people listed as  emergency  contacts.  Failure  in  such  efforts  should  not  prevent  Earth  Team  in  arranging  for  such  emergency treatment as may be necessary including emergency anesthesia, operation, hospitalization, and other treatment. I am aware that Earth Team assumes no liability for the costs or provision of evacuation and medical care in the event that such care is needed during or after this trip.  If I have a medical condition, I have been seen by a physician who is aware of my present condition, health history, and trip details and recommends that I be able to fully participate.