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UHS Ninth-Grade Backpacking Trip Form

First Namerequired

Last Namerequired

Middle Initial

Gender

Male Female

Medical Conditions (i.e., recent knee surgery, asthma, etc.)

Do you wear contact lenses?

yes no

Allergies (food, insect, or other environmental allergies)

Dietary Restrictions

Experience on this type of outing:

I - Beginner II - Intermediate III - Advanced

Current Medications

Parent/Guardian #1 Information:

Name

Home Address

Home Phone

Cell Phone

Work Address

Work Phone

Parent/Guardian #2 Information

Name

Home Address

Home Phone

Cell Phone

Work Address

Work Phone

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