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Previous KTAT Treks:

KTAT TRIP BACKGROUND INFORMATION FOR PHYSICIAN AND APPLICANT
Kirat Treks Adventure Travel (KTAT) operates its trips in a variety of conditions, some fairly primitive. Although this trip is not highly demanding physically, applicants need to be in good condition and able to walk up and down moderate hills on a daily basis. In some cases they may be a day or more away from modern medical facilities. In the interest of the applicant and other trip members, please consider the above description carefully when completing the medical form. We do need any relevant information. The physician completing this form may not be a relative of the applicant.
APPLICANT: The following medical information as completed by the physician is complete and true to the best of my knowledge. I recognize that falsification or omission of information is grounds for my removal from the trip.

Applicant Signature:
Date:

PHYSICIAN: Based on the description of the trip, a review of the applicant's medical history, and a physical examination, if needed, do you feel that this individual can participate in this trip?
(Check One) YES NO
Comments:

Does the applicant have any medical problems or is s/he taking any medication that we should be aware of?
(Check One) YES NO
If yes, please explain.

Does the applicant have any food or drug allergies that we should be aware of?
(Check One) YES NO
If yes, please explain.

NAME: , M.D.
ADDRESS:
PHONE:
PHYSICIAN'S SIGNATURE:
DATE:

PLEASE RETURN TO:
Kirat Treks
37702 Rushing Wind Court
Murrieta, CA 92563