Trip:

 

Today's Date:

 

Tours Trips Treks & Travel
Cabarete, Dominican Republic, tel: (809)543-3371, fax: (809)571-0995, info@4tdomrep.com, 4tdomrep.com
Standard Medical Information and Assumption of Risk Form

First Name Last Name Citizenship
Passport No. D.O.B. Blood Type
Name of Insurance Co. Policy No.
Address Zip/Postal Code
City State/Province Country
Day Tel Eve Tel Fax
Email

Medical Questionnaire
The adventure activities in which you will be participating are challenging and will require a reasonable level of fitness, strength and endurance. It is your responsibility to ensure that you have the appropriate level of fitness. These activities are not recommended for those with major disabilities, illnesses or infirmities. If you have any questions regarding your ability to participate, please consult your doctor to ensure that you are sufficiently fit and healthy. You should take into account that medical and other facilities in the Dominican Republic are likely to be inferior to those of your home country.


Do you have a history of the following conditions? Yes No
Heart or circulatory disease, angina or heart attack    
Raised blood pressure    
Respiratory disease    
Asthma/Hay fever    
Epilepsy    
Diabetes    
Back injuries    
Joint or dislocation injuries    
Heat-stroke or severe dehydration    
Faint or blackout spells    
Blood or bleeding disorders    

 

Are you currently being treated for a medical condition?


Please list any medications you take regularly:

 

Are you pregnant?

 

Please specify any allergies:  
Insects
 
Medications
 
Food
 

 

Please specify any dietary requirements. (e.g. vegetarianism)

 

Is there anything else that we should know about that could affect your ability to participate in adventure activities?


If yes, please elaborate.

 

 

 

Assumption of Risk and Waiver
I understand that there are inherent risks of serious injury or even death possible with adventure tourism activities. I hereby, intending to be legally bound, for myself, my heirs, and assigns, executors and administrators, waive and release forever any and all liability, and all claims for damages against Tours Trips Treks & Travel S.A., Administrators, Volunteers, and/or Employees for any and all injuries and/or losses I/my son/my daughter/my ward may sustain associated with participation in Tours Trips Treks & Travel S.A.'s activities. Please initial: ________


Assumption of Responsibility
I understand that there are inherent risks in adventure travel, such as biking, hiking, cascading and/or whale watching. I acknowledge that part of the enjoyment and excitement of adventure travel is derived from participating in travel and activities with concepts of safety and comfort different from those of "everyday" life. I agree that it is my personal responsibility to fully participate in all instructional sessions before and during the tour, and to understand how the equipment works. I agree to immediately stop using the equipment if found to be damaged or not function properly. I assume responsibility for my own safe behavior, as well as a role in insuring the safety of those with whom I travel. Please initial: ________


Medical Treatment Release
If medical care is required for me/ my son/my daughter/my ward in conjunction with any Tours Trips Treks & Travel S.A. activity or related transportation, and if normal permission is not available in a timely manner, the undersigned authorizes appropriate medical care as deemed necessary by emergency medical personnel, a physician, or the medical facility providing treatment. Please initial: ________

Treatment Release
In case of an emergency, I hereby authorize the following individual not traveling with me on Tours Trips Treks & Travel S.A. activities to be contacted and ASSUME RESPONSIBILITY FOR ME IN CASE OF AN EMERGENCY that renders me incapable of communication or making competent decisions.

Name Relationship
Address
City State/Province Zip/Postal Code
Day Tel Eve Tel Cell/Pager
Fax Email

I hereby certify to Tours Trips Treks & Travel & Aguatours Dominicana, S.A. that I am solely responsible for my medical, psychological and physical condition for the duration of my tour with Tours Trips Treks & Travel. I am unaware of any medical, psychological and physical problems that would, in any way, impair my ability to safely participate in this tour. Should any medical, psychological or physical problems arise during the course of my tour with Tours Trips Treks & Travel, I am solely responsible for financial costs and expenses related to obtaining any and all medical, psychological and physical care that I may need. I am solely responsible for having adequate insurance coverage for any such care, including, but not limited to, adequate insurance coverage for the costs and expenses of trip cancellation, evacuation, baggage loss or damage, trip interruption, travel accident/sickness, and medical care.

Please print name

 

Signature

 

Signature of Parent/Guardian (if participant is under 18 years old)

 

Please fax or mail to Tours Trips Treks & Travel. Participant confirmation is partially dependent upon receipt of Medical Information & Assumption of Responsibility form

This form is valid for all Tours Trips Treks & Travel Tours within a 4-month period of the date indicated above.
This information will be used to manage any health concerns that may arise while participant is on a Tours Trips Treks & Travel activity. Alternative contact and medical information will be used in a medical emergency. If you have questions about the collection or use of this information, contact the Manager at (809)543-3371.
Tours Trips Treks & Travel is operated with Aguatours Dominicana S.A. in the Dominican Republic.