OLT Medical Form - Backpacking Workshops 2025

Medical History Form It is advised by WTA’s physician advisor that volunteers and workshop participants be in good physical condition to participate in WTA work parties and events. Thoroughly completing the participation questionnaire will support WTA in creating a safe and inclusive environment for our events, including assessing individual readiness based on medical history. These work parties and events may require physically and mentally demanding exertion, including extended hiking or backpacking, for multiple days in a row. These work parties and events may be in remote locations without easy access to medical facilities or means of contacting rescue and medical personnel. WTA is requesting this information in the interest of the safety of both you and other crew members. The answers you provide will help your crew leader and WTA staff be better prepared to respond in an emergency. WTA may contact you to discuss your capacity to successfully complete the work parties and events for which you have registered. This form is valid for work parties and events during this calendar year. Information on this form is confidential and only reviewed by WTA staff. Thank you for your participation and information during this process.

Participant Name

Date of Birth: (MM/DD/YYYY)

Address

Emergency Contact Information

Name:

Alternate Emergency Contact

Name:

Relationship:

Phone number:

Do you carry an anaphylaxis kit?

Yes (If yes, please list below) No

Please List:
Allergy(s) Reaction/ what happens (date of last reaction) Medications

Do you have any dietary restrictions or preferences? Please contact us if you have questions about our ability to accommodate your needs

Do you have any allergies, including medication?

NoYes (If Yes, Please list below)

Please note type and severity :

Medical History:
Describe any injuries, operations or hospitalizations you've experienced in the past year.

Describe any illness or pre-existing conditions. For example: hepatitis, lyme disease, heart or lung conditions

Are you taking any medications? List type, dosage, frequency of use,side effects and purpose

Do you have any heat illness concerns or circulation issues due to cold weather?

Please state below any other health conditions, limitations or restrictions of which you are aware. Some examples include: asthmatic, orthopedic, diabetic or cardiac concerns, limited vision or hearing

By (virtually) signing here I agree that all conditions, symptoms, lifestyle factors, allergies and medications noted above are accurate.

Contact Information