Course Code from AMGA Website
Medical Information
Who should we contact in case of emergency?
What is her/his relationship to you?
Emergency Contact Phone Number
Do you have diabetes?---YesNo
How well is it under control?
Do you have a history of seizures?---YesNo
Do you have heart disease?---YesNo
How well is it managed?
Do you have a history or or currently have asthma?---YesNo
If you use an inhaler, will you have it with you?---YesNo
Do you have a history of anaphylaxis or allergies?---YesNo
If so, will you have an EpiPen or other prescribed medications with you?---YesNo
Do you have relevant musculoskeletal injuries or related surgeries? If so, please explain.
Do you have problems with vision or hearing? If so, please explain.
Do you have any other health issues that would prevent you from fully participating in activities provided by Vertical Voyages?---YesNo
If so, please explain.
Are you under the influence of illegal drugs or alcohol?---YesNo
Do you have medical insurance?---YesNo
If so, who is your provider?
Additional Information
Where did you take you SPI course?
Who was your course director?
Did they have a co-instructor? If so, who?
Do you have a current first aid certification (CPR, WFA, WRF)?---YesNo
I have read and understood all of the above questions and answered them truthfully.I Agree
