Health and Emergency Contact Info

Please fill out this form before meeting on the stream. This allows me to be aware of any extra care or precautions.

Name *

First

Last

Date

Phone

Email *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Name *

First

Last

Phone *

Relationship *

Name *

First

Last

Phone

Relationship

Primary Care Provider's Name

Phone

City/State

Please List Existing Health Conditions

Allergies

Medications

Other Health Notes

Please acknowledge each of the below

I understand that this activity includes standing, walking, and may include strenuous physical activity. I am in good health and able to participate these activities.
I authorize Journey on the Fly or its Agent to contact 911 on my behalf in case of emergency.

Signature (by typing name as signature, I acknowledge the information on this form is accurate.

Date