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College Outdoors

Peru Trek Health & Diet Questionnaire

The following information is for our trip leaders’ file only and remains strictly confidential.  

It is critical to fill out the health and diet questionnaire thoroughly indicating all current medications, past injuries, and any present conditions.  Failure to do so could put yourself or other participants at risk.  

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(Only required for current students)
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(i.e. 5ft 6in)
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(i.e. 135lbs)
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For example, he/him, she/her, they/them
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Please check Yes or No to the following conditions. For each item that you answer "yes", please describe in detail in the space provided below.

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Note: Due to the nature of outdoor trips and the distance and time to definitive medical care, we may (in the case of medical conditions that could put you at serious risk in a remote setting) ask you to discuss the trip you're applying for with your physician for their advice and require their permission to place you on the trip.
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If no, please either complete the information below (some fields may not apply), email a scan of both sides of your card to kori@lclark.edu, or, if you are on campus, bring your medical insurance card to the College Outdoors office in Templeton 244.
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