Hodgeman Co. Farm Bureau With The Pioneer Woman Travelers Health & Participation Form

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Tour Dates: April 14 & 15, 2018 -
Online Health & Participation Form

Complete 4 Steps: 1. Registration 2. Health Form 3.Payment & 4. Hotel Reservation

Last Name *

First Name *

Health Insurance Company *

Member's Insurance Number *

Emergency Contact (Name & Cell Phone) *

Health - check any physical condition the tour staff or medical personnel should be aware. (Confidential)

Allergy to Insect stings

Diabetes

Heart Conditions

Ear Infection

Currently Pregnant

Fainting spells, headaches, allergies

Wear Glasses or Contacts

Row 3

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Allergy to any drugs? Type Yes or No with drugs listed *

Personal Physician Name & Phone Number *

Prescribed Medications - please list (or type None) *

Last Tetanus immunization date *

Other conditions - please be specific

List Any Dietary Needs - please be specific

Participation - I agree that Hodgeman County Farm Bureau & K-State Research and Extension - Hodgeman County will NOT be responsible in case of injury or illness. I specifically agree to hold HGCoFB and KSRE, HG Co blameless to any claim for damages for any accident or injury of any kind resulting form participation in activities associated with the tour. I agree that photos/video taken will be used for the promotion of the event. Photos/video will not be sold to any other organization. *

Yes, I have read the participation clause and agree to the terms and conditions.

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