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Participant Registration Form
Name
(Required)
First
Last
Phone
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Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Email
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Date of Birth
MM slash DD slash YYYY
Occupation
Who to contact in an emergency:
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Relationship to you:
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Emergency contact telephone number:
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Do you have Diabetes?
(Required)
Yes
No
How well is it under control?
(Required)
Do you have a history of Seizures?
(Required)
Yes
No
How well is it under control?
(Required)
Do you have Heart Disease?
(Required)
Yes
No
Do you have a history of or currently have Asthma?
(Required)
Yes
No
If you use an inhaler, do you have it with you?
(Required)
Yes
No
Do you have a history of analphylaxis or allergies?
(Required)
Yes
No
If so, do you have an EpiPen or other prescribed medications with you?
(Required)
Yes
No
Do you have relevant musculoskeletal injuries or related surgeries?
(Required)
Do you have problems with vision or hearing?
(Required)
To the best of your knowledge, do you have any other medical or health issues that would prevent you from fully participating in activities provided by Mountain Skills Climbing Guides?
(Required)
Do you have medical insurance?
(Required)
Yes
No
Who is your carrier?
(Required)
Are you under the influence of illegal drugs or alcohol?
(Required)
Yes
No
How did you find out about Mtn. Skills?
Do you have any previous climbing experience?
(Required)
Yes
No
Explain:
Signature
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Date
(Required)
MM slash DD slash YYYY
Guide Confirmation
(Required)
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