Alaska Arctic Medical/Dietary Information & Waiver Form

The remote destination you will be visiting during your Alaska tour lacks quick access to medical facilities and professional medical care. In fact, advanced life support and aid can take hours, if not days, to reach. In our effort to help manage the risks associated with delayed care, you can help us by answering some personal medical questions, as well as abiding by our recommendations. All guides working for “Hugh Rose Photography” are certified in Emergency Wilderness Medicine and we do carry a satellite phone for emergency purposes while traveling on the Dalton Highway.

Name*

First Last

Email*

Emergency contact name*

First Last

Relationship to emergency contact*

Emergency contact phone*

City/State/Country of emergency contact*

City State / Province / Region Country

Arrival Flight Information

Arrival Date*

Flight #*

Airline*

Time*

:

Departure Flight Information

Departure Date*

Flight #*

Airline*

Time*

:

Questions

Do you have a history of heart problems?*

Do you have a history of seizures?*

Do you have a history of asthma?*

Are you allergic to any substances?*

Do you have a history of anaphylaxis?*

Do you have any other medical condition that we should be aware of?*

Further Explain Questions

If you answered yes to any of the above questions, please describe your condition more thoroughly here. Specifically, we would like to know how well managed the condition is; whether or not you take medications for the condition; whether or not you have any side effects from the medication; and the last time you had to visit an emergency room as a result of the condition.

Our Recommendations

We recommend that you consult your physician if you answered yes to any of the above questions. Your doctor may be able to offer advice regarding whether or not this trip is appropriate for you, and he or she might be able to offer advice regarding whether or not you should modify your activities, daily routine or your medications. We recommend that you abide by all of your existing medication regimes, and that your medication routine remain uninterrupted immediately prior to as well as during your tour. If for some reason, you choose to alter your existing medication routine, please let us know.

Dietary Questions

It's important for us to know if you have any dietary restrictions, food allergies, or dietary preferences. Please answer the below questions - all are required. If it doesn't pertain to you just write "None".

Dietary Restrictions*

i.e. Vegan, Vegetarian, Gluten-free etc.

Food Allergies*

Dietary preferences*

Alcoholic drink preference

Daytime excursion drink preference

i.e. water, coke, iced tea, diet coke etc.

Camera Gear Rental

Please indicate if you would like to rent any camera gear:

Loaner Gear

Please indicate if you would like to borrow any gear (boots or bean bag) and if boots please indicate the size needed:

Waiver

I have read through all of the trip information for the Photo Tour in Alaska's Arctic, including the trip description and I understand that medical facilities and professional medical care may not be available in the remote locations during my visit to Alaska. I consider my physical condition sufficient to participate in this trip, and I also realize that there are risks inherent when engaging in physical activities in such remote locations. I therefore do not hold Hugh Rose liable for circumstances beyond his control.

Name*

First Last

Typed Signature*

Date*

Name

This field is for validation purposes and should be left unchanged.