Name
*
First Name
Last Name
Email
*
Participant Phone Number
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Primary Emergency Contact
*
First Name
Last Name
Primary Emergency Contact Phone Number
*
(###)
###
####
Secondary Emergency Contact
First Name
Last Name
Secondary Emergency Contact Phone Number
(###)
###
####
Please select the option that best describes your swimming ability.
*
Please select the option that best describes your level of experience and comfort in the wilderness.
*
Have you ever been paddling before?
*
Have you ever paddled in whitewater rapids before?
*
Please provide a brief description of anything you are nervous about in regard to camping in the wilderness or wilderness travel.
Please provide a brief description of what you are most excited for!
Health Card #
Date of Birth
*
MM
DD
YYYY
Height
*
Weight
*
What is your current gender identity?
*
Male
Female
Transgender Male/Transman/FTM
Transgender Female/Transwoman/MTF
Gender Queer
Other
Decline to answer
What sex were you assigned at birth?
*
Male
Female
Other
Decline to Answer
Do you have any physical limitations that may affect your ability to participate fully in Packraft Adventure Canada programs?
*
If you answered yes to the question above, please provide detail.
Have you had any of the following?
*
If you checked any of the boxes above, please provide detail about each that apply to you.
Do you have problems with any of the following?
*
If you checked any of the boxes above, please provide detail about each that apply to you.
Do you have or have you experienced any of the following cardiovascular conditions?
*
If you checked any of the boxes above, please provide detail about each that apply to you.
Do you have any of the following medical conditions or issues?
*
If you checked any of the boxes above, please provide detail about each that apply to you.
Do you take any prescription medications regularly?
*
If you checked yes, please provide a detailed description of the medications and doses below.
Do you have any allergies (seasonal/food/medication etc.)
*
If you checked yes, please provide a detailed description of your allergies below. Please include a description of the date and severity of your most recent reaction.
Have you had physical therapy or treatment for any medical issues or injuries in the last 5 years?
*
If you checked yes, please provide a detailed description of the injury/illness and the treatment you received.
Do you have any chronic illness or injury that we should be aware of?
*
If you checked yes, please provide a detailed description of the injury/illness below.
Is there any other information we should be aware of to help facilitate your safety and enjoyment?
Do you have any food allergies?
*
If you answered yes to the question above please give a description of the allergy, your last reaction, and the severity of a typical reaction.
Have you ever had an anaphylactic allergic reaction?
*
Do you have any dietary restrictions that require a modified menu?
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If you answered yes to the question above, please describe the nature of the restriction (i.e. vegetarian, gluten-free etc.) and provide any suggestions for substitutes, preferred meals, etc.
Are there any foods you simply don't enjoy or would refuse to eat?
*
If you answered yes to the question above, please provide a description of the food(s) you dislike/would prefer not to eat.
Please check any/all of the things below that you enjoy.
Please select the option that best describes your eating habits.
*
Please select the option that best describes your daily food intake.
*
Is there any other information we should be aware of to help facilitate your enjoyment and meals on trip?
How did you hear about Packraft Adventure Canada?
PAC Website
Google Search
Google Ads
Facebook
Instagram
Referred by a friend
Other
Omissions and innaccurate statements may affect the ability of Packraft Adventure Canada and its representatives to safely and effectively deliver their programs.
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