CROSSROADS TOURS
EMERGENCY RELEASE FORM

NAME ____________________________DATE ______________

ADDRESS
______________________________________________________

______________________________________________________

HOME PHONE ________________WORK PHONE _____________
AGE ___

IN CASE OF AN EMERGENCY,  NOTIFY
_______________________________

HOME PHONE __________WORK PHONE ___________________

AUTHORIZATION

Crossroads Tours assumes no liability for injury or damage arising from
results of participation unless due to willful fault or gross negligence on the
part of Crossroads Tours.  Due to the strenuous nature of some activities,
the participant is urged to consult his physician concerning his/her fitness to
participate.  All Nature Tours present certain inherent risks and hazards,
which the participant is urges to consider, and which the participant
assumes.  In case of emergency, I consent to medical treatment.


SIGNED __________________________ DATE _______________

Note:  I give _____/ do not give ______ permission to be included in
individual and /or group photographs for use by Crossroads Tours.

***********
ADDITIONAL INFORMATION

The following information requested is needed so that we may better
understand and serve your needs.  The staff will hold all information
submitted in strict confidence.

1. Physicians  Name __________________Phone ______________

2. Insurance Provider _______________Policy No. ______________

3. Please list handicapping condition(s)________________________

4. Are you able to transfer from wheelchair to another chair by yourself?

Please explain, if
applicable:_________________________________________

PLEASE CIRCLE YES or NO

5. Do you have any speech difficulty?                        Yes                No        

6. Do you have any hearing difficulty?                        Yes                No

7. Are you on medication?
If so, what medication?  What side effects, if any?

8. Do you have seizures?                                         Yes                  No

9. What type of seizures? _____ Grand Mal  ____ Petit Mal  ______other

10. Do you have any physical signals before having a seizure?

11. Do you have allergies?                                          Yes                 No
If yes, specify:

Emergency treatment, if any?

12. Do you have any dietary problem?
If yes, specify:

13. Are there any other medical concerns that we should know about?


ADDITIONAL COMMENTS:




SIGNATURE __________________________ DATE _________

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