Name:__________________________________________________________________________

Address:________________________________________________________________________

City/ State/ Zip:___________________________________________________________________

Date of Last Tetanus:_______________________________________________________________

In case of an emergency please list 2 contacts and phone numbers:

1) ___________________________________ (_______)_______________________________

2)___________________________________ (_______)________________________________

Medical History: Facts concerning your medical history including allergies, medications being taken and any physical impairment of which a physician or your hunting guide should be alerted:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________