Adults participating in certain events hosted by the Virginia Department of Forestry will complete this form and submit to the program organizer.

SECTION 1 – Participant Information
Name:
Last Name	First Name	M.I.
Email:	Gender:
Preferred Phone No.: Preferred Phone No.:	Alternate Phone No.:
Address:
Mailing Address	City	State	Zip Code
SECTION 2 – Emergency Information
Emergency Contact Name:	Relationship:
Preferred Phone No.: Preferred Phone No.:	Alternate Phone No.:
Are you covered by medical insurance?	Yes	No	If yes, please complete in full:
Carrier:	Policy No.:	Group No.:
SECTION 3 – Medical History Information
Do you have any allergies to medicine, food, plant, animal or insect?	Yes	No	If yes, explain below.
Do you have any special dietary needs? (allergy restriction, vegetarian, etc.)	Yes	No	If yes, explain below.
Do you have any current health concerns, medical needs or special care/restrictions?	Yes	No	If yes, explain below.
Do you have any relevant past medical concerns or activity restrictions?	Yes	No	If yes, explain below.
Is any medication being taken now?	Yes	No	If yes, explain below.
Do you have any additional medical information that should be known to staff?	Yes	No	If yes, explain below.