Loading...

Alpine Endeavors Health History

FULL DISCLOSURE OF THE HEALTH ISSUES ON THIS FORM IS IMPORTANT FOR MITIGATING THE RISK TO YOU AND OTHERS IN THE EVENT OF AN ADVERSE MEDICAL EVENT. THE INFORMATION YOU PROVIDE MAY ASSIST PEOPLE IN THE UNLIKELY EVENT OF AN ACCIDENT. THEREFORE, BEFORE YOU FILL THIS FORM OUT, PLEASE READ IT CAREFULLY; FULL AND ACCURATE COMPLETION OF ALL SECTIONS IS VERY IMPORTANT.

 May 30, 2025 

First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Information
Your Pronouns
None
She/Her/Hers
He/Him/His
They/Them/Theirs
Ze/Hir/Hirs
Ey/Em/Eir
Height *
Weight *
Are you taking any medications for any medical issues?*
No
Yes
If "Yes" to medications, which ones and what are they for? Include side effects.
Anaphylaxis/Allergies?*
No
Yes
If "Yes" what anaphylaxis/allergies?
Musculoskeletal Injuries?*
No
Yes
If "Yes" what musculoskeletal injuries?
History of heart conditions?*
No
Yes
If "Yes" what heart conditions?
Seizures?*
No
Yes
If "Yes" anything we need to be aware of with seizures?
Diabetes?*
No
Yes
If "Yes" anything specific we need to know about diabetes?
Asthma?*
No
Yes
If "Yes" will you have any inhaler with you?
Poor Vision?*
No
Yes
If "Yes" any specific we should know about poor vision?
Poor hearing?*
No
Yes
If "Yes" any specific we should know about poor hearing?
History of heat or solar injury?*
No
Yes
If "Yes" any specific we should know about heat or solar injury?
History of frostbite?*
No
Yes
If "Yes" any specific we should know about frostbite?
History of altitude sickness?*
No
Yes
If "Yes" any specific we should know about altitude sickness?
Swimming ability?*
None
Beginner
Intermediate
Advanced
Expert
First Aid Training?*
None
First Aid
Wilderness First Aid
Wilderness First Responder
EMT or WEMT
Advanced Medical Training
Do you have dentures/false teeth?*
No
Yes

Please advise us on anything else you feel we should be aware of:

Please let us know your previous climbing experiences so we can best plan your day:
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's Information
Your Pronouns
None
She/Her/Hers
He/Him/His
They/Them/Theirs
Ze/Hir/Hirs
Ey/Em/Eir
Height *
Weight *
Are you taking any medications for any medical issues?*
No
Yes
If "Yes" to medications, which ones and what are they for? Include side effects.
Anaphylaxis/Allergies?*
No
Yes
If "Yes" what anaphylaxis/allergies?
Musculoskeletal Injuries?*
No
Yes
If "Yes" what musculoskeletal injuries?
History of heart conditions?*
No
Yes
If "Yes" what heart conditions?
Seizures?*
No
Yes
If "Yes" anything we need to be aware of with seizures?
Diabetes?*
No
Yes
If "Yes" anything specific we need to know about diabetes?
Asthma?*
No
Yes
If "Yes" will you have any inhaler with you?
Poor Vision?*
No
Yes
If "Yes" any specific we should know about poor vision?
Poor hearing?*
No
Yes
If "Yes" any specific we should know about poor hearing?
History of heat or solar injury?*
No
Yes
If "Yes" any specific we should know about heat or solar injury?
History of frostbite?*
No
Yes
If "Yes" any specific we should know about frostbite?
History of altitude sickness?*
No
Yes
If "Yes" any specific we should know about altitude sickness?
Swimming ability?*
None
Beginner
Intermediate
Advanced
Expert
First Aid Training?*
None
First Aid
Wilderness First Aid
Wilderness First Responder
EMT or WEMT
Advanced Medical Training
Do you have dentures/false teeth?*
No
Yes

Please advise us on anything else you feel we should be aware of:

Please let us know your previous climbing experiences so we can best plan your day:
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Information
Your Pronouns
None
She/Her/Hers
He/Him/His
They/Them/Theirs
Ze/Hir/Hirs
Ey/Em/Eir
Height *
Weight *
Are you taking any medications for any medical issues?*
No
Yes
If "Yes" to medications, which ones and what are they for? Include side effects.
Anaphylaxis/Allergies?*
No
Yes
If "Yes" what anaphylaxis/allergies?
Musculoskeletal Injuries?*
No
Yes
If "Yes" what musculoskeletal injuries?
History of heart conditions?*
No
Yes
If "Yes" what heart conditions?
Seizures?*
No
Yes
If "Yes" anything we need to be aware of with seizures?
Diabetes?*
No
Yes
If "Yes" anything specific we need to know about diabetes?
Asthma?*
No
Yes
If "Yes" will you have any inhaler with you?
Poor Vision?*
No
Yes
If "Yes" any specific we should know about poor vision?
Poor hearing?*
No
Yes
If "Yes" any specific we should know about poor hearing?
History of heat or solar injury?*
No
Yes
If "Yes" any specific we should know about heat or solar injury?
History of frostbite?*
No
Yes
If "Yes" any specific we should know about frostbite?
History of altitude sickness?*
No
Yes
If "Yes" any specific we should know about altitude sickness?
Swimming ability?*
None
Beginner
Intermediate
Advanced
Expert
First Aid Training?*
None
First Aid
Wilderness First Aid
Wilderness First Responder
EMT or WEMT
Advanced Medical Training
Do you have dentures/false teeth?*
No
Yes

Please advise us on anything else you feel we should be aware of:

Please let us know your previous climbing experiences so we can best plan your day:
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information
Your Pronouns
None
She/Her/Hers
He/Him/His
They/Them/Theirs
Ze/Hir/Hirs
Ey/Em/Eir
Height *
Weight *
Are you taking any medications for any medical issues?*
No
Yes
If "Yes" to medications, which ones and what are they for? Include side effects.
Anaphylaxis/Allergies?*
No
Yes
If "Yes" what anaphylaxis/allergies?
Musculoskeletal Injuries?*
No
Yes
If "Yes" what musculoskeletal injuries?
History of heart conditions?*
No
Yes
If "Yes" what heart conditions?
Seizures?*
No
Yes
If "Yes" anything we need to be aware of with seizures?
Diabetes?*
No
Yes
If "Yes" anything specific we need to know about diabetes?
Asthma?*
No
Yes
If "Yes" will you have any inhaler with you?
Poor Vision?*
No
Yes
If "Yes" any specific we should know about poor vision?
Poor hearing?*
No
Yes
If "Yes" any specific we should know about poor hearing?
History of heat or solar injury?*
No
Yes
If "Yes" any specific we should know about heat or solar injury?
History of frostbite?*
No
Yes
If "Yes" any specific we should know about frostbite?
History of altitude sickness?*
No
Yes
If "Yes" any specific we should know about altitude sickness?
Swimming ability?*
None
Beginner
Intermediate
Advanced
Expert
First Aid Training?*
None
First Aid
Wilderness First Aid
Wilderness First Responder
EMT or WEMT
Advanced Medical Training
Do you have dentures/false teeth?*
No
Yes

Please advise us on anything else you feel we should be aware of:

Please let us know your previous climbing experiences so we can best plan your day:
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information
Your Pronouns
None
She/Her/Hers
He/Him/His
They/Them/Theirs
Ze/Hir/Hirs
Ey/Em/Eir
Height *
Weight *
Are you taking any medications for any medical issues?*
No
Yes
If "Yes" to medications, which ones and what are they for? Include side effects.
Anaphylaxis/Allergies?*
No
Yes
If "Yes" what anaphylaxis/allergies?
Musculoskeletal Injuries?*
No
Yes
If "Yes" what musculoskeletal injuries?
History of heart conditions?*
No
Yes
If "Yes" what heart conditions?
Seizures?*
No
Yes
If "Yes" anything we need to be aware of with seizures?
Diabetes?*
No
Yes
If "Yes" anything specific we need to know about diabetes?
Asthma?*
No
Yes
If "Yes" will you have any inhaler with you?
Poor Vision?*
No
Yes
If "Yes" any specific we should know about poor vision?
Poor hearing?*
No
Yes
If "Yes" any specific we should know about poor hearing?
History of heat or solar injury?*
No
Yes
If "Yes" any specific we should know about heat or solar injury?
History of frostbite?*
No
Yes
If "Yes" any specific we should know about frostbite?
History of altitude sickness?*
No
Yes
If "Yes" any specific we should know about altitude sickness?
Swimming ability?*
None
Beginner
Intermediate
Advanced
Expert
First Aid Training?*
None
First Aid
Wilderness First Aid
Wilderness First Responder
EMT or WEMT
Advanced Medical Training
Do you have dentures/false teeth?*
No
Yes

Please advise us on anything else you feel we should be aware of:

Please let us know your previous climbing experiences so we can best plan your day:
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information
Your Pronouns
None
She/Her/Hers
He/Him/His
They/Them/Theirs
Ze/Hir/Hirs
Ey/Em/Eir
Height *
Weight *
Are you taking any medications for any medical issues?*
No
Yes
If "Yes" to medications, which ones and what are they for? Include side effects.
Anaphylaxis/Allergies?*
No
Yes
If "Yes" what anaphylaxis/allergies?
Musculoskeletal Injuries?*
No
Yes
If "Yes" what musculoskeletal injuries?
History of heart conditions?*
No
Yes
If "Yes" what heart conditions?
Seizures?*
No
Yes
If "Yes" anything we need to be aware of with seizures?
Diabetes?*
No
Yes
If "Yes" anything specific we need to know about diabetes?
Asthma?*
No
Yes
If "Yes" will you have any inhaler with you?
Poor Vision?*
No
Yes
If "Yes" any specific we should know about poor vision?
Poor hearing?*
No
Yes
If "Yes" any specific we should know about poor hearing?
History of heat or solar injury?*
No
Yes
If "Yes" any specific we should know about heat or solar injury?
History of frostbite?*
No
Yes
If "Yes" any specific we should know about frostbite?
History of altitude sickness?*
No
Yes
If "Yes" any specific we should know about altitude sickness?
Swimming ability?*
None
Beginner
Intermediate
Advanced
Expert
First Aid Training?*
None
First Aid
Wilderness First Aid
Wilderness First Responder
EMT or WEMT
Advanced Medical Training
Do you have dentures/false teeth?*
No
Yes

Please advise us on anything else you feel we should be aware of:

Please let us know your previous climbing experiences so we can best plan your day:
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information
Your Pronouns
None
She/Her/Hers
He/Him/His
They/Them/Theirs
Ze/Hir/Hirs
Ey/Em/Eir
Height *
Weight *
Are you taking any medications for any medical issues?*
No
Yes
If "Yes" to medications, which ones and what are they for? Include side effects.
Anaphylaxis/Allergies?*
No
Yes
If "Yes" what anaphylaxis/allergies?
Musculoskeletal Injuries?*
No
Yes
If "Yes" what musculoskeletal injuries?
History of heart conditions?*
No
Yes
If "Yes" what heart conditions?
Seizures?*
No
Yes
If "Yes" anything we need to be aware of with seizures?
Diabetes?*
No
Yes
If "Yes" anything specific we need to know about diabetes?
Asthma?*
No
Yes
If "Yes" will you have any inhaler with you?
Poor Vision?*
No
Yes
If "Yes" any specific we should know about poor vision?
Poor hearing?*
No
Yes
If "Yes" any specific we should know about poor hearing?
History of heat or solar injury?*
No
Yes
If "Yes" any specific we should know about heat or solar injury?
History of frostbite?*
No
Yes
If "Yes" any specific we should know about frostbite?
History of altitude sickness?*
No
Yes
If "Yes" any specific we should know about altitude sickness?
Swimming ability?*
None
Beginner
Intermediate
Advanced
Expert
First Aid Training?*
None
First Aid
Wilderness First Aid
Wilderness First Responder
EMT or WEMT
Advanced Medical Training
Do you have dentures/false teeth?*
No
Yes

Please advise us on anything else you feel we should be aware of:

Please let us know your previous climbing experiences so we can best plan your day:
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information
Your Pronouns
None
She/Her/Hers
He/Him/His
They/Them/Theirs
Ze/Hir/Hirs
Ey/Em/Eir
Height *
Weight *
Are you taking any medications for any medical issues?*
No
Yes
If "Yes" to medications, which ones and what are they for? Include side effects.
Anaphylaxis/Allergies?*
No
Yes
If "Yes" what anaphylaxis/allergies?
Musculoskeletal Injuries?*
No
Yes
If "Yes" what musculoskeletal injuries?
History of heart conditions?*
No
Yes
If "Yes" what heart conditions?
Seizures?*
No
Yes
If "Yes" anything we need to be aware of with seizures?
Diabetes?*
No
Yes
If "Yes" anything specific we need to know about diabetes?
Asthma?*
No
Yes
If "Yes" will you have any inhaler with you?
Poor Vision?*
No
Yes
If "Yes" any specific we should know about poor vision?
Poor hearing?*
No
Yes
If "Yes" any specific we should know about poor hearing?
History of heat or solar injury?*
No
Yes
If "Yes" any specific we should know about heat or solar injury?
History of frostbite?*
No
Yes
If "Yes" any specific we should know about frostbite?
History of altitude sickness?*
No
Yes
If "Yes" any specific we should know about altitude sickness?
Swimming ability?*
None
Beginner
Intermediate
Advanced
Expert
First Aid Training?*
None
First Aid
Wilderness First Aid
Wilderness First Responder
EMT or WEMT
Advanced Medical Training
Do you have dentures/false teeth?*
No
Yes

Please advise us on anything else you feel we should be aware of:

Please let us know your previous climbing experiences so we can best plan your day:
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information
Your Pronouns
None
She/Her/Hers
He/Him/His
They/Them/Theirs
Ze/Hir/Hirs
Ey/Em/Eir
Height *
Weight *
Are you taking any medications for any medical issues?*
No
Yes
If "Yes" to medications, which ones and what are they for? Include side effects.
Anaphylaxis/Allergies?*
No
Yes
If "Yes" what anaphylaxis/allergies?
Musculoskeletal Injuries?*
No
Yes
If "Yes" what musculoskeletal injuries?
History of heart conditions?*
No
Yes
If "Yes" what heart conditions?
Seizures?*
No
Yes
If "Yes" anything we need to be aware of with seizures?
Diabetes?*
No
Yes
If "Yes" anything specific we need to know about diabetes?
Asthma?*
No
Yes
If "Yes" will you have any inhaler with you?
Poor Vision?*
No
Yes
If "Yes" any specific we should know about poor vision?
Poor hearing?*
No
Yes
If "Yes" any specific we should know about poor hearing?
History of heat or solar injury?*
No
Yes
If "Yes" any specific we should know about heat or solar injury?
History of frostbite?*
No
Yes
If "Yes" any specific we should know about frostbite?
History of altitude sickness?*
No
Yes
If "Yes" any specific we should know about altitude sickness?
Swimming ability?*
None
Beginner
Intermediate
Advanced
Expert
First Aid Training?*
None
First Aid
Wilderness First Aid
Wilderness First Responder
EMT or WEMT
Advanced Medical Training
Do you have dentures/false teeth?*
No
Yes

Please advise us on anything else you feel we should be aware of:

Please let us know your previous climbing experiences so we can best plan your day:
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information
Your Pronouns
None
She/Her/Hers
He/Him/His
They/Them/Theirs
Ze/Hir/Hirs
Ey/Em/Eir
Height *
Weight *
Are you taking any medications for any medical issues?*
No
Yes
If "Yes" to medications, which ones and what are they for? Include side effects.
Anaphylaxis/Allergies?*
No
Yes
If "Yes" what anaphylaxis/allergies?
Musculoskeletal Injuries?*
No
Yes
If "Yes" what musculoskeletal injuries?
History of heart conditions?*
No
Yes
If "Yes" what heart conditions?
Seizures?*
No
Yes
If "Yes" anything we need to be aware of with seizures?
Diabetes?*
No
Yes
If "Yes" anything specific we need to know about diabetes?
Asthma?*
No
Yes
If "Yes" will you have any inhaler with you?
Poor Vision?*
No
Yes
If "Yes" any specific we should know about poor vision?
Poor hearing?*
No
Yes
If "Yes" any specific we should know about poor hearing?
History of heat or solar injury?*
No
Yes
If "Yes" any specific we should know about heat or solar injury?
History of frostbite?*
No
Yes
If "Yes" any specific we should know about frostbite?
History of altitude sickness?*
No
Yes
If "Yes" any specific we should know about altitude sickness?
Swimming ability?*
None
Beginner
Intermediate
Advanced
Expert
First Aid Training?*
None
First Aid
Wilderness First Aid
Wilderness First Responder
EMT or WEMT
Advanced Medical Training
Do you have dentures/false teeth?*
No
Yes

Please advise us on anything else you feel we should be aware of:

Please let us know your previous climbing experiences so we can best plan your day:
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address
Email*
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Information
Your Pronouns
None
She/Her/Hers
He/Him/His
They/Them/Theirs
Ze/Hir/Hirs
Ey/Em/Eir
Height *
Weight *
Are you taking any medications for any medical issues?*
No
Yes
If "Yes" to medications, which ones and what are they for? Include side effects.
Anaphylaxis/Allergies?*
No
Yes
If "Yes" what anaphylaxis/allergies?
Musculoskeletal Injuries?*
No
Yes
If "Yes" what musculoskeletal injuries?
History of heart conditions?*
No
Yes
If "Yes" what heart conditions?
Seizures?*
No
Yes
If "Yes" anything we need to be aware of with seizures?
Diabetes?*
No
Yes
If "Yes" anything specific we need to know about diabetes?
Asthma?*
No
Yes
If "Yes" will you have any inhaler with you?
Poor Vision?*
No
Yes
If "Yes" any specific we should know about poor vision?
Poor hearing?*
No
Yes
If "Yes" any specific we should know about poor hearing?
History of heat or solar injury?*
No
Yes
If "Yes" any specific we should know about heat or solar injury?
History of frostbite?*
No
Yes
If "Yes" any specific we should know about frostbite?
History of altitude sickness?*
No
Yes
If "Yes" any specific we should know about altitude sickness?
Swimming ability?*
None
Beginner
Intermediate
Advanced
Expert
First Aid Training?*
None
First Aid
Wilderness First Aid
Wilderness First Responder
EMT or WEMT
Advanced Medical Training
Do you have dentures/false teeth?*
No
Yes

Please advise us on anything else you feel we should be aware of:

Please let us know your previous climbing experiences so we can best plan your day:
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!