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Passenger Health and Emergency Info Form
Cruise Dates______________________________
Name (First)______________________________
Name (Last) ______________________________
Home Address__________________________________________
City_________________State__Zip Code____________________
Country______________Email_____________________________
Day Phone_______________Evening Phone__________________
Do you have any health conditions, allergies, religious convictions or legal arrangements which may affect your program participation that we need to know about prior to emergency treatment? No__Yes__Please explain________________________________
_______________________________________________________________________
Please list current medications_______________________________________________
Do you have any physical conditions that we could consider as we plan your involvement in this adventure program? No__ Yes__Please explain____________________________
_______________________________________________________________________
Whom should we notify in case of a medical emergency?
Name_____________________Relationship______________Phone_________________
Address__________________________________________Alt.Phone_______________
Doctor’sName____________________________________Phone___________________
Please give us the name of your health/accident insurance carrier(s) and appropriate policy certifications number(s)
Name of Carrier_________________________Policy Number_____________________
Name of Carrier_________________________Policy Number_____________________
HOMELAND SECURITY REQUIREMENTS
All Zodiac passengers must board in one group, accompanied by a badged crew member. Passengers from different vessels must not mingle and must board at separate times. Long term parking and other errands must be completed before boarding as passengers may not leave vessel after boarding. Luggage must remain at all times in the control of the owner and only placed on vessel when passenger boards.
Zodiac operates within hours of an international border requiring strict compliance.
I,______________________am registered to participate in the sailing program aboard the Schooner Zodiac, hosted by the Vessel Zodiac Corporation. I am physically fit to participate in this sailing program and have no physical pre-conditions that will make my participation dangerous to my health. I am responsible for monitoring my ability and my limits. I hereby release the Vessel Zodiac Corporation from any and all liabilities to me with respect to injury, illness or loss.
Signature____________________________________________Date________________
I hereby release any photographs taken of me for use in promotions or publications
Signature____________________________________________Date________________
