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College Outdoors

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 students at risk.  

("NST" is sufficient for new student trip registration)
(i.e. 5ft 6in)
(i.e. 135lbs)
xxx-xxx-xxxx
If you answered "yes", please describe in detail in the space provided below.
If you answered "yes", please describe in detail in the space provided below.
If you answered "yes", please describe in detail in the space provided below.
If you answered "yes", please describe in detail in the space provided below.
If you answered "yes", please describe in detail in the space provided below.
If you answered "yes", please describe in detail in the space provided below.
If you answered "yes", please describe in detail in the space provided below.
If you answered "yes", please describe in detail in the space provided below.
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.
If no, please bring in (Templeton 244) or email a photocopy of both sides of your medical insurance card, or complete the following (some fields may not apply)
There's an additional $5/day charge to provide vegan meals or special diets such as gluten free meals for New Student Trips in August. This fee can be waived for any medically-based allergies or intollerances.