Name:
Permanent Address:
City: State: ZIP:
Summer Address:
Are you planning on living in staff housing (guides only)? Yes No
Are you available the first week of May through -Sept 8, 2012? Yes No
If not, what is your availability?
Birth Date:
Cell Phone Number: Email:
Driver's License Number: DL State:
Endorsements:
Traffic Citations:
Medic Alert Tag: Yes No Contacts: Yes No
Allergies/Foods:
Allergies/Other:
Medications:
Physical Limitations:
Other Medical Info:
Do you speak any foreign languages? How fluent are you?
GENERAL INFORMATION
Will you be bringing a vehicle? Yes No
Jacket Size (check one): Small Medium Large X-Large
T-Shirt Size: Small Medium Large X-Large
EMERGENCY INFORMATION
Emergency Contact: Relationship:
Address: City: State:
Home Phone: Cell Phone: Work Phone:
In case of emergency, I authorize CIRI, Alaska Tourism and Sunny Cove Sea Kayaking Company to release the above medical information to medical personel.
Signed: Initials: Date: