R6, 2023-09-20

NOTE: Powell River Sea Kayak and Cabana Desolation Eco Resort does not accept paper waivers, please submit electronically.

PRSK Medical & Dietary Information

In order to ensure complete safety on our tours, Powell River Sea Kayak requires participants complete the following medical & dietary information form. This information will help the guides and cooks properly prepare for the tour.

Although Powell River Sea Kayak guides have training and up-to-date certification in Advanced Wilderness First-Aid, Powell River Sea Kayak Ltd. assumes no responsibility for medical care. Information on this form is completely confidential.

Each individual touring with Powell River Sea Kayak (including children) needs to have this form filled out individually.

Note: Certain extremely restrictive dietary requests like keto & paleo diets, or celiac disease (on camping tours only), are not able to be accommodated due to our remote camps and resort location. If your specific dietary need is not listed in the options below, please contact us immediately to confirm.

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Trip Information

Trip Name

Please select your multi-day trip from the drop down box.

Trip Start Date

Trip End Date

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Personal Information

Full Name

Date of Birth

Year Month Day

Height

Weight

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Address

Street Address

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

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Contact Information

Day Phone

Evening Phone

Email Address

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Emergency Contact

Name

Relationship

Phone Number

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Medical Conditions

Have you ever had, or are you prone to any of the following?

Heart Condition

Yes

High Blood Pressure

Yes

Diabetes

Yes

Asthma

Yes

Depression

Yes

Surgery within last year

Yes

Joint Dislocation

Yes

Seizure Disorders

Yes

Broken Bones

Yes

Nose Bleeds

Yes

Critical Stress

Yes

Chronic Head Aches

Yes

Any chronic physical limitations (bad back, joints, etc)

Yes

Have you been under a doctor's care in the last 12 months?

Yes

Details

If you answered Yes to any of the above, please take a moment to provide details so we can better manage your safety during the tour.

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Allergies

Do you have any known allergies, or have you ever had a severe allergic reaction?

Yes

Was the reaction localized?

Yes

If applicable.

Was the reaction systemic?

Yes

If applicable.

Please describe what causes the reaction, what happens to you, and how you manage a reaction

If applicable.

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Medications

Are you currently taking any prescription or non-prescription medications?

Yes

Please list the type of medications, the dosages, and the conditions you are taking them for

If applicable.

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Tetanus Inoculation

What was the date of your last tetanus inoculation?

Tetanus boosters are good for 10 years. A current one is highly recommended for participation on all our multi-day tours.

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Diet Information

Vegetarian

Do you follow a vegetarian diet?

Yes

Is fish okay?

Yes

If answered 'Yes' above.

Are ethically and locally sourced meats okay?

Yes

If answered 'Yes' above.

Additional details here

If answered 'Yes' above.

Seafood

Do you eat seafood?

Yes

Are salmon, prawns or other types of fish okay?

Yes

If answered 'No' above

Additional details here

If answered 'No' above.

Gluten Free

Do you follow a gluten or wheat free diet?

Yes

Please note, we offer a gluten free menu for a 5% surcharge. Please only select 'Yes' if you would like the gluten free menu.

Are you celiac?

Yes

If answered 'Yes' above'. Note we are not able to accommodate celiac diets on camping tours.

Additional details here

If answered 'Yes' above.

Dairy Free

Do you follow a dairy free diet?

Yes

Please note, we offer a dairy free menu for a 5% surcharge. Please only select 'Yes' if you would like the dairy free menu.

Are small amounts of dairy in cooking / baking okay?

Yes

If answered 'Yes' above.

Additional details here

If answered 'Yes' above'

Other Specific Intolerances

A 5% surcharge per person, per item will be added to your reservation for any changes to our regular menu as a result of checking any boxes on this list (as mentioned on the Booking Form and as per the Rates & Policies page on our website).

Do you have any dietary requirements due to the following specific food intolerances?

None

Nuts

Eggs (as part of a meal, can be used in baking)

Other*

Please contact us soon to discuss diet particulars, and provide details here

If applicable. *Examples of diets we cannot cater to on camping tours: celiac, complete egg-free, seed/oil/soy-free, FODMAP, nightshade allergies, strict vegan diets, keto/paleo.

Coffee

Do you drink coffee?

Yes

How may cups a day?

If answered 'Yes' above.

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Fitness Information

What do you believe your fitness level to be?

Poor

Fair

Good

Excellent

Are you comfortable on the water?

Yes

Can you swim?

Yes

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General Information

Do you wear glasses or contact lenses?

Yes

Do you smoke?

Yes

Have you had a serious illness in the last year?

Yes

Are you pregnant?

Yes

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Acknowledgment

Are you over 18?

Yes

Acknowledgement

Yes

I acknowledge that I have completed this medical form accurately, and truthfully, and to the best of my knowledge. I understand that any injury or illness that is aggravated by, or is a result of my participation in a sea kayak tour, is solely my responsibility. I understand that withholding information may contribute to injury or illness complications, and possibly compromise the care provided in the event of an emergency. I understand that it is my responsibility to inform Powell River Sea Kayak Ltd. before my tour begins, of any changes to the medical information that I have submitted.

Click to Sign

Parents must sign for their legal guardians.

Electronic Signature Consent

By checking here, you acknowledge you have read and understand the above terms, and are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

Medical & Dietary Information (Camping Tours)

For those joining an overnight camping tour with Powell River Sea Kayak. Please ensure that each member of your group (including children) has this form filled out individually well before the date of the tour. If you are booking for a group, please ensure that you email all group members this form using the button below.

Status: NEW

Read the document

Select Trip Name

Fill in Trip Start Date

Fill in Trip End Date

Fill in Full Name

Select Date of Birth

Fill in Height

Fill in Weight

Fill in Street Address

Fill in Address Line 2

Fill in City