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 12, 2024 

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's 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*
Second Participant's 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*
Third Participant's 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*
Fourth Participant's 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*
Fifth Participant's 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*
Sixth Participant's 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*
Seventh Participant's 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*
Eighth Participant's 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*
Ninth Participant's 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*
Tenth Participant's 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*
A signed copy of this waiver will be sent to the email address you provide.
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*
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!