Participant Information

SPI Assessment

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?

How well is it under control?

Do you have a history of seizures?

How well is it under control?

Do you have heart disease?

How well is it managed?

Do you have a history or or currently have asthma?

If you use an inhaler, will you have it with you?

Do you have a history of anaphylaxis or allergies?

If so, will you have an EpiPen or other prescribed medications with you?

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?

If so, please explain.

Are you under the influence of illegal drugs or alcohol?

Do you have medical insurance?

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)?

I have read and understood all of the above questions and answered them truthfully.
I Agree