Submit this form only if required

MEDICAL RELEASE FORM

Gig Harbor Stake Pioneer Trek 2014
This form must be completed and signed by a medical doctor for participants who answered yes to any of the
conditions listed on the Medical History portion of the Registration form. They will not be allowed to participate if
this form is not submitted. The examination must be current, within six weeks of the event date.
Participant ______________________________________________ Dates of Trek: July 22 26, 2014
Dear Doctor,
The above named person is requesting to participate in a wilderness program called a Pioneer Trek. Persons
suffering from any of the conditions listed below must obtain a physicians clearance before participating in this
program. The participants will be in a wilderness/desert setting for 5 days. The program includes strenuous hiking
while pulling/pushing a heavy wooden handcart. They will have ample food and water, but will be exposed to
excessive heat and exhaustion may occur. There are other outdoor activities that they will engage in as well. Also
be aware that medical facilities are limited in the area.
Please consider the following conditions in your decision (as well as other medical problems which may be
aggravated by or interfere with the aforementioned conditions):
Arthritis
Asthma
Epilepsy
Emotional issues requiring medication
Fainting spells
Ulcers
Celiac Disease
Major bone or joint injuries
High blood pressure
Surgery or serious illness
Heart trouble
Hypoglycemia
Diabetes
Chronic/recurring illness
Rheumatic Fever
Other medical condition(s) which may be aggravated
by extreme heat or strenuous activity

Individuals will be allowed to take medications for chronic conditions if the medication is prescribed and
accompanied by a doctors note of approval.
GENERAL APPRAISAL:
( ) APPROVAL: I find no medical problems which I consider incompatible with this program.
( ) LIMITED APPROVAL: Participate is subject to limitations as listed on a separate attached document.
( ) DISAPPROVAL: This individual has medical problems which, in my opinion, clearly constitute unacceptable
hazards to his/her health and safety in this program.

Date: __________________________ Signature: __________________________________________________
Doctors Name (print): _________________________________________________________________________
Address: _______________________________________________________ Phone : _____________________