Canoe Journey Emergency Medical Form

Name(Required)

First Middle Last

Address(Required)

Street Address Apt # City State / Province / Region ZIP / Postal Code Country

Mailing Address (if different from above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Date of Birth(Required)

Tribal Affliation(Required)

Enrollment #(Required)

If you have no tribal affiliation, please write N/A for affiliation and enrollment number.

Medical Information

Do you have medical insurance?(Required)

Yes

No*

*If you do not have medical insurance, you will be solely responsible for any costs associated with medical treatment that you receive while on Canoe Journey. The Snoqualmie Indian Tribe is not liable to cover the costs for medical care.

Blood Type(Required)

Primary Doctor's Name

Doctor's Phone

Doctor's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Medical Insurance Company(Required)

Policy Subscriber Name(Required)

First Last

Policy Number #(Required)

Group Number #(Required)

Major/Behavioral Health Conditions(Required)

Current Medications(Required)

Allergies(Required)

Dietary Restrictions(Required)

Emergency Contacts (at least two required)

Emergency Contact Name(Required)

First Last

Relationship to Participant(Required)

Phone(Required)

Emergency Contact Name(Required)

First Last

Relationship to Participant(Required)

Phone(Required)

Emergency Contact Name

First Last

Relationship to Participant

Phone

Participant Signature(Required)

Parent or Guardian Name

First Last

Parent or Guardian Signature

Date(Required)

Please provide a copy of your Tribal or Washington State I.D.(Required)

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 256 MB, Max. files: 1.