This medical form helps us ensure a safe experience for you. If we have any questions about your ability to complete the trip, we will call and discuss it with you. If, after this discussion it is decided that it would be unwise for you to participate on that particular trip, we will either recommend a less strenuous trip or refund all payments made to The Wolfden at Nakitsilik and or Nakitsilik Outdoors Adventures. Unfortunately, we cannot cover or refund costs of medical examinations or other expenses you incur preparing for a trip.

Name ______________________________
Trip Name & Dates_______________________

Street ____________________ City ______________ Prov/State__________________

Country _______________ Postal or Zip Code ________________

Home telephone ( ____)____________ Business Telephone ( ____)____________

Email ________________

Age ________ Birthdate (mo/day/yr) ___________________ __Male __Female

Person to be notified in case of illness or injury

Name: ____________________________________________________

Street ____________________ City ______________ Prov/State__________________

Country _______________ Postal or Zip Code ________________

Home telephone ( ____)____________ Business Telephone ( ____)____________

Relationship ___________________

1. Are you covered by a public/provincial medical plan? ______________________________

By which province or state? _______________ Health Card Number ___________________

2. Do you have other private medical insurance coverage? ______________

Name of insurance company ________________________ Policy number ________________

Address _______________________________________
Phone ( ____)____________

PART II. MEDICAL HISTORY To be completed by Applicant. Parent or Guardian must also sign this form, if Applicant is under 18 years of age.

Please note: If you arrive at the start of the trip with a pre-existing condition or injury which is not indicated on your medical form and you are subsequently refused the trip because of this condition, you will not receive any refund. Please understand that this is to ensure your safety and the safety of the other trip members.

1. Give a brief statement of your general health

_________________________________________

Height_________ Weight__________Shoe Size___________

2. Do you have or have you had, any past, serious or ongoing medical problems or conditions? Yes ___ No ___

3. Are you taking any medications (list in detail all medications and dosages) N.B. If you are taking medications, please bring an extra week's supply of the medication on the trip in separate, waterproof, unbreakable containers, along with dosage instructions. Also bring medication for allergies and seizures if indicated Yes ___ No ___

4. Have you had any surgeries? Give approx. dates/details. Yes ___ No___

5. Are you allergic to any of the following? (please list all allergies and describe nature and severity of reaction)
medications Yes ___ No ___
foods: Yes ___ No ___
insect bites: Yes ___ No ___
other Yes ___ No ___

What medications are needed to control the reaction?

___________________________________________________________

Do you smoke? If so, how much? Yes ___ No ___

7. Do you have problems with vision or hearing? (describe) Yes ___ No ___

8. Do you have motion sickness? (describe severity) Yes ___ No ___

9. Do you have high blood pressure? (describe) Yes ___ No ___

10. Do you have heart murmurs; episodes of irregular heart beat; shortness of breath or chest pain on exertion? (if so, describe symptoms) Yes ___ No ___

11. Do you have asthma? If so, has the condition been stable for the past year?
Yes ___ No ___

12. Do you require a special diet? (If vegetarian, please list what you do not eat)?
Yes ___ No ___

13. Do you have claustrophobia, agoraphobia, acrophobia? (strong fear of confined places, open areas, heights)? Yes ___ No ___

14. Do you have problems with your neck, back, arms, ankles or knees that limit your exercise? Yes ___ No ___

15. Have you had frostbite or a reaction to cold temperatures? (describe severity if so) Yes ___ No ___

16. Does your health prevent you from participating in any physical activities?
Yes ___ No ___

17. Any person with normal physical and mental capacity can usually expect to complete a trip with The Wolfden at Nakitsilik and or Nakitsilik Outdoors Adventures but preliminary conditioning is strongly advised. The Wolfden at Nakitsilik and or Nakitsilik Outdoors Adventures reserves the right to decline any applicant whose physical condition is not suitable for the trip. Please describe in detail what you do routinely to maintain fitness (mention activities and frequency).

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

If you are over 30 years of age and any of the following conditions apply to you, we STRONGLY SUGGEST that you discuss with your physician the advisability of taking a stress electrocardiogram. Please check the following if applicable:

___ high blood pressure ___ smoke one or more packs of cigarettes daily

___ family history of heart disease ___ long-term sedentary lifestyle

___ overweight or obesity ___ previous cardiovascular disease

___ diabetes

Consent is hereby given for the applicant to participate on a trip with The Wolfden at Nakitsilik and or Nakitsilik Outdoors Adventures and permission is given for any emergency anesthesia, operation, hospitalization or other treatment which might become necessary. I understand that the program involves physically and mentally strenuous activity in a remote wilderness area far removed from the facilities of civilization.

The information provided above is a complete and accurate statement of the physical and psychological factors, which may affect my participation on a trip with The Wolfden at Nakitsilik and or Nakitsilik Outdoors Adventures. I realize that failure to disclose such information could result in serious harm to myself and fellow participants and agree to indemnify and hold The Wolfden at Nakitsilik and or Nakitsilik Outdoors Adventures harmless if all relevant information is not disclosed.

Name (please print) ______________________________________________

Applicant’s Signature:__________________________________________

Signature of parent or guardian (if under 18 years of age) ________________________

Please note: The Wolfden at Nakitsilik and Nakitsilik Outdoors Adventures has a strictly enforced ZERO TOLERANCE policy to illicit drugs or substances.

Due to the prevailing insurance situation and legal atmosphere in Canada, we must insist that each participant be familiar with and agree to the following document. If you have any questions regarding any of the contents, please contact us prior to signing the document. The form must be completed and submitted with your final payment. No one may participate in a Wolfden at Nakitsilik or Nakitsilik Outdoors Adventures dog sled trip without submitting this document.

Insurance coverage is the responsibility of each individual participant.

Cancellation/medical/evacuation insurance and travel coverage are strongly recommended and available through travel agents.

Thank you in advance for your compliance with these requests.

Please read carefully.

Please note that this document must be signed and received in the mail at our office before you can depart with the group. By signing this document you are giving up certain legal rights.

To: The Wolfden at Nakitsilik &/or Nakitsilik Outdoors Adventures

and to: Her Majesty the Queen in Right of Canada, The Province of British Columbia and The Thompson - Nicola Regional District.

Wilderness dogsled trips include dogsledding on trails and crossing overflow, running, harnessing and caring for dogs, winter camping and other associated activities including but not limited to snowshoeing, cross country skiing, ice fishing.

In consideration of The Wolfden at Nakitsilik and or Nakitsilik Outdoors Adventures accepting my application I agree to this Release of Claims and Waiver of Liability. I understand that dogsledding adventures involve certain dangers, not all of which can be listed here.

Among the more obvious and frequent are:

1. Inclement and unpredictable weather, which may cause injury due to extremes of heat and cold and which may prevent travel to, from or within an area;

2. Hazards related to dogsled travel near lakes, creeks & rivers;

3. Submersion in cold water resulting from upset or falling off dogsled;

4. Unfamiliar country, where the participant may become lost, get off route or be separated from the rest of the party;

5. Remoteness of location with poor communications and inability to get rescue or medical assistance quickly or easily;

6. Medical problems arising before, during or after the wilderness adventure or dogsled trip;

7. Illness related to change of diet or water source;

8. Transport by public or private motor vehicle, helicopter and light fixed-wing aircraft;

9. Natural hazards, including blizzards, overflow, steep/rough terrain, and the presence of wild animals; and

10. Failure to follow directions from the guide, including those specifying:

- staying with the group at all times unless the guide is consulted and provides consent.

- safe use of tools and other wilderness adventure trip and dogsled equipment.

I am not relying on any oral or written statements made by the Wolfden at Nakitsilik and or Nakitsilik Outdoors Adventures or its agents, whether in brochures, advertisements, videotapes, in individual conversations or otherwise to lead me to become involved in this program on any basis other than my assumption of the risks involved.

I accept all of the risks including the possibility of death, personal injury, property damage and loss resulting from my involvement with the trip I am taking with The Wolfden at Nakitsilik &/or Nakitsilik Outdoors Adventures.

I release The Wolfden at Nakitsilik & or Nakitsilik Outdoors Adventures, its officers, employees, guides, agents and representatives from any and all liability for any personal injury, death, property damage or loss I may suffer as a result of my participation in their trip, for any cause whatsoever (including negligence) on the part of The Wolfden at Nakitsilik and or Nakitsilik Outdoors Adventures, its officers, employees, guides, agents or representatives.

I certify that I am physically capable and fit to participate in this activity and I have no medical conditions or needs other than those listed in the Medical Information Form provided to The Wolfden at Nakitsilik & or Nakitsilik Outdoors Adventures.

I confirm that I am eighteen years of age or older. (Younger participants must have a parent or guardian read and sign this document.)

I confirm that I have read over this agreement before signing, that I understand it, and that it will be binding not only on me, but also on my heirs, my next of kin, my executors, administrators and assigns.

I agree that the laws of British Columbia govern this contract and that any legal concerns will be handled in the competent and fair courts in British Columbia Canada.

I hereby agree to permit other members of the trip to take film and photographic records of my participation in this tour.

Signed this ________ day of _____________________20________

at the City/Town/Village of________________________________

in the Province/State of___________________________________

Participant's Signature ________________________________

Print name:_________________________________________

Witness' Signature ___________________________________

Print name _________________________________________

This form does not need to be notarized.