Medical Questionnaire Form 2025

*Questions with a red asterisk, may not be left blank. If you select yes to an answer, please elaborate in the corresponding box. If you select No for an answer, please enter none or n/a in the corresponding box. The form will not submit if it is not completed properly.

This tour requires three forms, which you can complete online below: Medical Questionnaire, Release of Liability Form and the Accommodations and Trail Permit Form. Trip registration will not be approved until complete forms are submitted.

Please fill out the medical questionnaire completely. Health challenges may not preclude you from joining us on this adventure, however, the trip leaders must be aware of all medical concerns for your safety and the safety of other participants to determine eligibility for each participant.

Medical Form 2025

Medical Form 2025

General Information

Your First Name *

Your Last Name *

Your Email Address *

Checkboxes *

Female

Male

Address *

City *

State *

Country *

Cell phone Number *

Text Box

Alternate Number

Text Box

Describe your travel experience *

Date of Birth *

Age *

Height *

ie: 5'5"

Weight *

Primary Emergency Contact

First Name *

Last Name *

Relationship *

Email Address *

Cell phone Number *

Text Box

Alternate Number

Text Box

Secondary Emergency Contact

First Name

Last Name

Relationship

Work Phone Number

Email Address

Evacuation and Medical Insurance

We strongly encourage you to have medical and evacuation insurance and to bring your insurance card or other documentation with you on the trip.

Do you have Medical insurance? *

Yes

No

Adventure Travel to destinations that include high altitude trekking require purchase of travel insurance with medical and evacuation coverage. Please indicate that you understand this requirement by checking the box below. *

Yes

No

Allergies

Include all allergies to medicines, foods, insect bites and stings, animals and environment (dust pollen, etc)

Do you have any allergies? If no, select "no" here and type "none" in box to the right. *

Yes

No

List allergies, reactions and medications *

Do you require use of an EpiPen for medical treatment for any reason? *

Yes

No

If you require the use of Epipen for any medical treatment, please explain. If no, please write "none" in the box. *

Medications

List Medication Name, Dosage, Frequency, Side effects (known and potential) and Reason for Taking

List all medications here *

Medical History

Please answer the following medical history questions.

Have you had any illness or injury within the last 12 months? If no, select no here and enter "none" in box below *

Yes

No

If yes, please explain.

Have you had surgery or been hospitalized in the last year? If no, select no here and enter "none" in the box below *

Yes

No

If yes, please explain. *

Do you have asthma? If yes, do you require the use of an inhaler? If no, select No and enter none in the field below. *

Yes

No

If yes, please list any asthmas medications and explain conditions under which medications are needed and list the last date that you needed to use your inhaler for treatment. *

Do you have diabetes? If no, please enter no here and enter "none" in the box below *

Yes

No

If yes, please list any diabetes medications and frequency. *

Do you have any medications that will require refrigeration? *

Yes

No

Do you have a history of high blood pressure? If no, select "no" here and type "none" in box explanation box. *

Yes

No

If you have a history of High Blood Pressure, is it currently controlled by medication? If no, please explain. *

Do you have a history of heart disease? If no, select "no" here and type "none" in box explanation box. *

Yes

No

If yes, please explain. If no, select "no" here and type "none" in box. *

Do you wear contact lenses or corrective eye ware to see? If you wear prescription glasses or contacts, please bring a spare.

Yes

No

Do you have any history of eye or vision problems (e.g. glaucoma, detached retina)?If no, please enter no here and enter "none" in the box below *

Yes

No

If yes, please explain. If no, select "no" here and type "none" in box explanation box.

Do you have any problems with your hearing? If no, select "no" here and type "none" in box explanation box. *

Yes

No

If yes, please explain.

Are you pregnant? *

Yes

No

Do you have any bone, joint, or muscle problems? If no, please enter no here and enter "none" in the box below *

Yes

No

If yes, please explain.

Have you ever had a seizure? If no, please enter no here and enter "none" in the box below *

Yes

No

If yes, please explain. *

Have you ever experienced altitude sickness? If no, please enter no here and enter "none" in the box below *

Yes

No

If yes, please explain. *

Do you have any other medical issues that might affect your participation in this trip? If no, enter no here and "none" in the box below *

Yes

No

If yes, please explain. *

The outing may require extended, vigorous physical activity and may be mentally and emotionally demanding while traveling in isolated areas without medical facilities, medical providers, or means of contacting emergency rescue services. Please state below all physical or mental limitations and restrictions of which you are aware: If you have no such limitations, please type none and enter initials here: *

Have you had a Tetanus shot or booster within the last 10 years?: *

Yes

No

Do you have any food allergies or special dietary needs? If no, select "no" here and type "none" in box explanation box. *

Yes

No

If yes, please explain. *

By entering my digital signature below, I agree that all information is accurate included in this form is accurate and I agree to notify the trip leader immediately if there is a change to any of the information on this form.

Tour Name and Date: *

Signature of the Participant *

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Date *

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Release of Liability Form

Acknowledgment of Outing Member Responsibility, Express Assumption of Risk, and Release of Liability

I understand that during my participation in this TJ Hiker Inc. Adventure Outings and Active Vacations, herein referred to as “Outing”, I may be exposed to a variety of hazards and risks, foreseen or unforeseen, which are inherent in each Outing and cannot be eliminated without destroying the unique character of the Outing. These inherent risks include, but are not limited to, the dangers of serious personal physical and/or emotional injury, property damage, illness, and death, herein referred to as “Injuries, Illness, and Damages”, from exposure to the hazards of travel and TJ Hiker, Inc. has not tried to contradict or minimize my understanding of these risks. I know that Injuries, Illness and Damages can occur by natural causes, natural disaster, or activities of other persons, animals, trip members, trip leaders and assistants or third parties, either as a result of negligence, or because of other reasons. I understand that risks of such Injuries, Illness and Damages are involved in adventure travel and/or active vacations such as a TJ Hiker, Inc. Outing, and I appreciate that I may have to exercise extra care for my own person and for others around me in the face of such hazards.

Initial Here

I understand that on this Outing, there may not be rescue or medical facilities or expertise necessary to deal with Illnesses, Injuries, Natural Disasters and Damages to which I may be exposed. I understand that I am personally responsible for purchasing trip and evacuation insurance for any TJ Hiker, Inc. outing.

Initial Here

I understand that a comprehensive travel insurance policy that includes medical, trip interruption and cancellation is required for this trip and that failure to obtain said policy, I accept responsibility for any losses incurred.

Initial Here

I further understand that I am responsible for following and understanding all government regulations, foreign or domestic, governing travel and travel restrictions and requirements pertaining to COVID 19, including those for re-entry into the United States. I am responsible for the cost and for obtaining any COVID 19 tests required for the transportation via ground, sea, or air travel within the required time period for such travel. I understand failure to do so or in the event of a positive COVID 19 test, those consequences financial or other thereto, for example expenses due to rescheduling travel, lodging or medical expenses, etc. are my responsibility.Exposure to Covid-19. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 while traveling. Such exposure or infection may result in personal injury, illness, permanent disability, and possible death. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with TJ Hiker, Inc., or its partners and affiliates

Initial Here

In consideration for my acceptance as participation this Outing, and the services and amenities to be provided by TJ Hiker, Inc. in-connection with the Outing, I confirm my understanding that: •I have read any rules and conditions applicable to the Outing made available to me; I will pay any costs and fees for the Outing; and I acknowledge my participation is at the discretion of the leader. TJ Hiker, Inc., TJ Hiker Inc. group leader(s) and third party leader(s) may at any time during the outing, terminate my participation in the outing for any reason, including if it is determined by TJ Hiker, Inc. outing leader and/or third party leaders/associates or other representatives, that your continued participation is unsafe to self, others or property and/or if your continued participation is disruptive to the other Group participants and/or nature of the Outing. If such action occurs, you are responsible for any additional costs incurred as a result of said action. •The Outing officially begins and ends at the location(s) designated by the TJ Hiker, Inc., leader, agent, assistant(s) or designated third parties. The Outing does not include carpooling, transportation, or transit to and from the Outing, and I am personally responsible for all risks associated with this travel. This does not apply to authorized transportation provided by TJ Hiker Inc., designated trip leaders, designated assistants and/or designated third parties during the Outing. •If I decide to leave early and not to complete the Outing as planned, I assume all risks inherent in my decision to leave and waive all liability against TJ Hiker, Inc., TJ Hiker Inc. trip leaders and assistants or third parties arising from that decision. Likewise, if the leader has concluded the Outing or terminated my participation in the outing for any reason, and I decide to go forward without the leader and/or leader(s) permission, I assume all risks inherent in my decision to go forward and waive all liability against TJ Hiker, Inc., TJ Hiker, Inc. trip leaders and assistants or third parties arising from that decision. •This Agreement is intended to be as broad and inclusive as is permitted by law. If any provision or any part of any provision of this Agreement is held to be invalid or legally unenforceable for any reason, the remainder of this Agreement shall not be affected thereby and shall remain valid and fully enforceable. •To the fullest extent allowed by law, I agree to waive, discharge claims, and release from liability TJ Hiker, Inc., its officers, directors, employees, agents, third party agents and leaders from any and all liability on account of, or in any way resulting from Injuries and Damages, even if caused by negligence of TJ Hiker, Inc., its officers, directors, employees, agents, and leaders, in any way connected with this Outing. I further agree to hold harmless, TJ Hiker, Inc., its officers, directors, employees, agents, and leaders from any claims, damages, and injuries to participant on the outing. I understand and intend that this assumption of risk and release is binding upon my heirs, executors, administrator’s and assigns, and includes any minors accompanying me on the Outing. Furthermore, I understand that this TJ Hiker, Inc. Outing may require physical conditioning specific to the Outing, and that I am responsible for understanding the demands for the Outing for which I am enrolled to participate and that I am solely responsible for my own physical conditioning and preparation for this Outing. I understand that if it is determined by a group leader, guide, or agent that I am unfit for this Outing, TJ Hiker, Inc. group leader, agent, or guide may deny my participation in any or all of the itinerary. If such action occurs, I am fully responsible for any costs incurred as a result of being denied participation in said activity or outing and I do not hold TJ Hiker, Inc, its officers, directors, employees, agents, Third-Party contractor’s and/or Group Leaders from any claims due to such action.

Initial Here

I have read this document in its entirety and I freely and voluntarily assume all risks of such Injuries, Illness and Damages and notwithstanding such risks, I agree to participate in the Outing. Supply your email address to receive periodic communications from TJ Hiker, Inc. Adventure Outings.

*If a minor is going on the trip, the minor's guardian must sign on the “I have read the Acknowledgment of Participant Responsibility, Express Assumption of Risk, and Release of Liability in its entirety and I freely and voluntarily assume all risks of such Injuries and Damages and notwithstanding such risks, I agree to participate in the Outing”.

Reservation and Cancellation Policy: I understand that to confirm my booking, a non-refundable deposit in the amount provided by TJ Hiker Inc, will be paid in full. The balance will be due 120 days prior to the first day of the tour. Reservations made within 120 days of the first day of the tour require payment to be made in full at the time of the reservation and are non-refundable. If a cancellation is made within 120 days before the first day of the tour, the full payment will be retained and is non-refundable. There will be no refunds within 120 days of the first day of the tour. Tours that include flights are subject to surcharge fees for any flight price increases at the time of your booking. Travel insurance with medical, trip interruption and emergency evacuation are required.

Name as it appears on Passport: *

Expiration Date

Address *

Email Address *

Phone Number *

Emergency Contact Name/Relation: *

Contact Information: Phone/Email Address *

Signature *

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Rooming Preference

Rooming Preference

Your Full name as it appears on the passport you will be using for this trip: *

Your Passport Number

If you are renewing your passport, fill in the current number and update us later. It will corrected on the reservations and tickets at an extra cost of $15 per person.

Your Passport Nationality

If you are renewing your passport, fill in the current number and update us later. It will corrected on the reservations and tickets at an extra cost of $15 per person.

Preferred room type: *

Double Occupancy - 2 Beds

Double Occupancy - 1 Bed

Single Occupancy -Single Supplement Applies

Occupancy Preference: (Note: some treks require double occupancy for the tent portions of the trip and are not included in the pricing of the tour.) *

I am traveling solo, and I would like to be paired up with another solo traveler. If no other solo travelers are available to pair up, I understand that I will be responsible for the single supplement fees.

I prefer to have single occupancy and understand there will be a single supplement charge

I have a travel companion that has or will be registering for this trip and rooming with me.

Name of Trip: *

Your Age *

Your Birthday *

Your Gender

Female

Male

Your Address *

Your Email *

Your Phone *

Your Dietary requirements *

List "none" if no dietary considerations are needed

First and last name of your travel companion if sharing a room:

Travel Companion Email and phone number:

Comments

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