Please complete and return to Nature Tours of Yukon Inc.

1. Name:______________________________________________

Name of Tour: ___________________________________

Departure date: _______________________

2. Height: _____________ Weight: ________________

Sex: ______________ Birth date: _________________

3. Evaluate your health (check one):

Fair __________ Good __________ Excellent __________

4. Evaluate your physical condition:

Below Average ______ Average ______ Above Average ______

5. Are you on any medication?

Yes ______ No ______

If yes;

Medication: ____________________________

Medicated for? ______________________________________

6. Do you have any physical limitations? Yes ______ No ______

If yes, please describe:_________________________________________________

7. List any allergies, dietary restrictions or other special needs:

_____________________________________________________________________

_____________________________________________________________________

8. List any major illnesses that may affect your participation in this trip:

_____________________________________________________________________

_____________________________________________________________________

9. Date of last tetanus inoculation:

_________________________________. (Must be current)

10. Please record your Health Care number for our records.

Number: ____________________________ Province/State: ________

I agree that I have answered the above questions to the best of my ability and that I am fully responsible for my own well being and physical condition while taking part in the above named expedition.

Signature: _________________________________________

Date: ________________________________

If you have any physical limitations or medical conditions that may limit your participation in the trip, please have your doctor remark on your physical condition with respect to your participation in this expedition, having read the brochure and the trip information package.

Remarks:

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Doctor's Signature: __________________________________

Date: ____________________________________

Doctor's Name: _____________________________________

Phone#: ____________________________________

Note: All of the above information will be kept strictly confidential and is requested for your safety and well being while on any trip with Nature Tours of Yukon.

Have you purchased trip cancellation/evacuation/medical insurance?