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ABSAROKA-BEARTOOTH OUTFITTERS MEDICAL INFORMATION FORM

 
Name

 
Emergency Contact

 
Telephone of Emergency Contact

 
Insurance Information

 
Are there medical issues that Absaroka-Beartooth Outfitters, EMS, or medical physicians attending your emergency care need to be aware of?
Yes        No
Examples: Allergic reactions to drugs, foods, insects, plants, etc., Heart conditions, Physical limitations
 
If yes, please list

 

 
Are you currently using medication?
Yes        No
 
If yes, please list medications and dosages

 

 

 
If a medical emergency occurs, I hereby grant permission to be transported if possible to the nearest medical facility. I hereby release Absaroka-Beartooth Outfitters, guides, and agents from any claims resulting from any injury or accident.
 
Date Participant/Legal Guardian

 
 
 

 

Absaroka-Beartooth Outfitters • P.O. Box 318 • Big Timber, MT 59011• (406) 579-3866 • email
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