Horizons Unlimited Wilderness Services Inc.
Box 1110 · La Ronge, SK S0J 1L0 · Canada
Toll-free: 1-877-511-2726 · Fax: 306-635-4420

Registration and Health Form

Please print both the Registration Form and Health Form that are on this page. Send the completed forms, along with your deposit, to Horizons Unlimited, Box 1110, La Ronge, SK S0J 1L0, Canada, as soon as possible.

Registration Form

Trip/Clinic Name _______________________________________________________

Name of Applicant _______________________________________________________

Phone Numbers - Home _____________________ Work ________________________

Fax __________________ E-mail _____________________________________

Address ________________________________________________________________

City ______________________________________ Prov/State ____________________

Postal/Zip Code _____________________ Country _____________________________

Please accept my 20% deposit:

Amount: __________ Cheque enclosed ___ Visa ___ Master Card ___ Money Order ___

Name on Card: ___________________________________________________________

Account Number: ______________________________________ Expiry date: ________

I recognize that I will be required to sign a document outlining the terms and conditions of participation in this activity and that the document must be received in our office prior to the trip’s departure. (See Agreement of Terms)

Signature: _______________________ Date: ________________

Health Form

Trip/Clinic Name: ________________________________________________________

Name of Applicant: _______________________________________________________

Doctor’s Name: ___________________________ Phone #: _______________________

1. Please record your Health Care Number for our records:

Number: ________________________ State or Province: ___________

2. Date of your last tetanus inoculation: ________________________ (must be current)

3. List any major illness that may affect your participation in this trip:

____________________________________________________________________

4. List any allergies or dietary restrictions: ____________________________________

_____________________________________________________________________

5. Do you have any physical handicaps? Yes __________ No ______________

If yes, please describe: _________________________________________________

6. Evaluate your health (check one): Fair _______ Good _______ Excellent _________

7. Evaluate your physical condition:

Below Average _________ Average ________ Above Average ________

I agree that I have answered the above questions to the best of my ability and that I am filly responsible for my own well being and physical condition while taking part in the above named expedition/clinic.

Signature: _______________________ Date: ________________