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Medical Disclosure Form

I, the undersigned, am providing this medical disclosure form (this “Disclosure”) to Thin Air Adventures Ltd. and their affiliates, to ascertain my fitness, (or the fitness of the person for whom I am completing this form) to participate in sightseeing tour packages, aerobatic flying, and otherwise flying in a variety of aircrafts (the “Services”). Thin Air Adventures is relying on the accuracy of this Disclosure to perform the Services. This Disclosure must be completed and provided to Thin Air Adventures prior to my participation (or the person for whom I am completing this form’s participation) in any Services. This Disclosure will supersede any previous verbal or written medical or health information I (or the person for whom I am completing this form) have provided. If there any changes to my health or medical status (or the health or medical status of the person for whom I am completing this form), I must update Thin Air Adventures immediately.

    Passenger Information

    Last Name, First Name

    Birthdate (DD/MM/YYYY)

    Telephone Number

    Email:

    Address

    Town/City

    Province/State

    Postal Code/Country

    Height

    Weight

    Emergency Contact

    Last Name, First Name

    Relationship

    Telephone Number

    Email:

    Health Declaration

    The following questions must be answered with “yes” or “no”:

    Do you (or the person for whom you are completing this form) currently have symptoms of, or have you been diagnosed with, pneumonia or coronavirus disease
    (COVID-19)?

    In the past 24 hours, have you (or the person for whom you are completing this form) had any of the following symptoms: fever, cough, runny nose, sore throat,
    loss of taste or smell, body aches, shortness of breath, diarrhea, nausea, or vomiting?

    Have you (or the person for whom you are completing this form) been advised by a health care worker or medical practitioner not to participate in activities similar to or the same as the Services?

    Have you (or the person for whom you are completing this form) been diagnosed
    with, or are being treated for, any short term or chronic illnesses or medical conditions?

    If you answered yes, please provide details here:

    Have you (or the person for whom you are completing this form) undergone any surgeries or medical procedures, or been hospitalized in the last year?

    If you answered yes, please provide details here:

    Have you (or the person for whom you are completing this form) been diagnosed with, or are being treated for, any of the following conditions or illnesses, or similar
    or related conditions or illnesses:

    Chronic Obstructive Pulmonary Disease, Shortness of Breath, Seizure, Epilepsy, Diabetes, Cardiac Failure, Asthma, Angina, Heart Attack, Heart Failure, Arrythmia, Valve Disease, High Blood Pressure, Respiratory Illness, or any condition or illness
    requiring supplemental oxygen.

    If you answered yes, please provide details here:

    Do you (or the person for whom you are completing this form) have any allergies?

    If you answered yes, please provide details here:

    Allergen:

    Symptom(s):

    Have you (or the person for whom you are completing this form) been diagnosed with, or are being treated for, any cognitive, behavioral, or psychiatric conditions that could affect your participation in the Services? For example, could you (or the person for whom you are completing this form) become agitated and pose safety risks or significant distress to others?

    If you answered yes, please provide details here:

    Is there any additional medical information you (or the person for whom you are completing this form) would like to disclose?

    If you answered yes, please provide details here:

    Mobility Accommodations

    Do you (or the person for whom you are completing this form), have any issues with, or need assistance with, any of the following: boarding, tolerating mild exertion (e.g. walking 100 meters) without symptoms, taking medication, or using medical devices?

    If you answered yes, please provide details here:

    I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD ALL OF THE QUESTIONS IN THIS THIS DISCLOSURE AND THAT THE INFORMATION PROVIDED HEREIN IS, TO THE BEST OF MY KNOWLEDGE, COMPLETE AND
    ACCURATE

    Signature

    Print Name

    Date