1.  Have you been on any other ADK trips?____ If so, please list the trips, years in which they were taken, and the names of the trip leaders:
 
 

2.  Please list any strenuous hiking or backpacking trips taken in the last three years and the approximate weight of the pack you carried:
 
 
 

3.  Do you have any plans to do any extended hiking, canoe camping or backpacking trips before this trip?     If so, where? Extended means 2-4 days in a row.
 
 

4.  Please describe physical activities you have engaged in during the past year, including those you do on a weekly or frequent basis. If hiking or backpacking, please include mileage and/or time of trips and locations:
 
 

5.  Please describe your strenuous hiking/backpacking experience, such as the number of years you have hiked, the types of terrain, etc.
 
 

6.  Do you have any critical dietary requirements? If so, please indicate:
 
 

7.  Are there any medical conditions limiting your activity? If so, please describe:
 
 

8.  Do you snore?    Yes    No      Do you smoke?                 Yes       No
 

9.  Do you have any allergies (such as food, bee stings, etc.)?               Yes     No
    If so, please list:
 

11. List any medications you are currently taking:
 

12. Will you be taking these with you on the trip?            Yes              No

13. Name any illness or condition for which you are now being treated, or have been  treated in the past 6 months:
 
 

14. Check any immunizations you have been given and the dates (as best you can remember) they were administered:

   TETANUS ____________  DPT _________ 

   TYPHOID ____________  POLIO ___________ OTHER______________ 

15.  Age___        Height        __    Weight _____ 
 

[    ]   I FULLY UNDERSTAND THE VIGOROUS NATURE OF THIS TRIP. IN THE EVENT OF AN EMERGENCY, PERMISSION IS GIVEN FOR OPERATION AND ANESTHESIA WHICH MIGHT BECOME NECESSARY AS REQUIRED BY A PHYSICIAN.
[    ]   MY HEALTH AND MEDICAL INSURANCE IS CURRENT AND I WILL CARRY MY MEDICAL INSURANCE CARD WITH ME.
 

SIGNED: _____________________________________    DATE_____________ 
            Applicant or Parent or Guardian (if under 18 years of age)

In order to advertise our ADK Outings, we like to put pictures on our web site (www.ADK.org).
Please sign below if we may use a photograph taken on the trip, which may include you, in our future publicity:

Signed: _______________________________________ 

SEND TO: Trip Leader:      Mary Coffin  328 Deepsprings Dr., Chittenango, N.Y. 13037