Last

First

Middle

Male/Female

Street Address                                                                          City                              State                              Zip

Home Phone

Cell Phone

Work Phone

Pager Number

Height/Weight

Eyes

Hair

Date of Birth

Medical History (Allergies or Special Conditions)

Emergency Contact

Relationship

Home Phone

Cell Phone

Departure Date

Departure Time

Return Date

 Return Time

Location Departed

Map        yes       no

Compass       yes       no

 Other Means of Communication

How Many People in Group Including yourself, their names, their age

Thorough Description of Destination

Thorough Description of Activity

Vehicle Make and Model

Vehicle Color

License Number

 State

Do you have your 10 Essentials            yes       no    Describe

Footwear Brand, Style, and Size.

Draw a picture of the tread pattern  of your footwear here

Clothing:    Describe (Colors and Materials) Shirt, Pants, Outerwear, Hat, Other