Medical Certificate & Traveler’s Profile


Please submit this form no later than 60 days prior to departure.

For your safety and that of your fellow travelers, good overall health and physical fitness are prerequisites for participating in any tour with Southwind Adventures. Travelers who are not in good health or who have serious, chronic medical conditions can create potentially dangerous situations by their presence on a trip. Participants should review our Trip Ratings and answer the questions below, listing any notable health conditions. On some trips you may encounter conditions listed for more than one rating, in which case the trip is rated according to the difficulty of the majority of activities. Fields marked with a star (*) are required.

A physician’s signature is required if you are participating in a Grade III or IV trip AND you meet the following conditions:

  • A “yes” answer to any of the first three questions of Part 1 below
  • If you are age 70 or older

* Traveler's Name:

* Trip:

Occupation:

Trip Rating:








Part 1


MUST be completed by all travelers. Please explain all "yes" answers

1) Do you have or have you ever been told by a doctor that you have diabetes, epilepsy, high blood pressure, heart disease, asthma or lung disease, ulcerative colitis or ulcers, any significant back, foot or leg problems, or any other diseases or conditions that could affect your participation on this trip?
 Yes No
If yes, explain:

2) Do you have any significant illnesses which require regular care of a doctor bi-monthly or more frequently?
 Yes No
If yes, explain:

3) Have you been hospitalized in the past 2 years?
 Yes No
If yes, explain:

**Please download and print our Medical Certificate PDF
if you are participating on a Grade III or IV program AND answered "yes" to any of the three questions above, and therefore require a physician's signature.**

4) Do you have any emotional or behavioral disorders (including phobias)?
 Yes No
If yes, explain:

5) Do you take medication regularly?
 Yes No
If yes, which ones and what for?

6) Do you have any allergies including allergic reactions to any drugs?
 Yes No
If yes, which ones and what effect?

SWA would like to have your regular physician's telephone number (or the examining physician if signature is required) as a contact in event of a medical emergency and/or to discuss any health conditions related to your participation.
* Physician's name:

* Physician phone number:



Part 2


Outdoor Experience

Hiking:
 None Basic Moderate Advanced

Camping:
 None Basic Moderate Advanced

Rafting:
 None Basic Moderate Advanced

Biking:
 None Basic Moderate Advanced

Any diet restrictions or food allergies? If vegetarian, please explain your needs (i.e. if you eat chicken or fish on occasion).

Special interests - what leisure activities do you enjoy?

If participating in a Class III or IV adventure, briefly describe relevant experience:

Have you been to Latin America before? If so, where did you go?

What are your expectations regarding this trip? Additional Comments?

I hereby attest that, to the best of my knowledge, the above statements are true and accurate. By checking this box, I am signing voluntarily.

Full name:

Child's name, if answering on behalf of a minor (under 18)

Email Address:

Today's date







Upon submitting this form, please wait until you get a “sent successfully” message. You will receive an automated email containing a copy for your records.