R67, 2020-10-21

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.


---

Trip Information

i.e. 5 Day Desolation Sound Camping Tour

---

Personal Information

---

Address

---

Contact Information

---

Emergency Contact

---

Medical Conditions

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


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.

---

Allergies

If applicable.

If applicable.

If applicable.

---

Medications

If applicable.

---

Tetanus Inoculation

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

---

Diet Information

Vegetarian

If answered 'Yes' above.

If answered 'Yes' above.

If answered 'Yes' above.

Seafood

If answered 'No' above

If answered 'No' above.

Gluten Free

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

If answered 'Yes' above'


If answered 'Yes' above.


Dairy Free

Please note, we offer a dairy free menu for a 5% surcharge. Please only select 'No' if you would like the dairy free menu.

If answered 'No' above.

If answered 'No' 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).

If applicable.


Coffee

If answered 'Yes' above.


---

Fitness Information

---

General Information

---

Acknowledgment

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.

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.