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  1. EXPRESS ASSUMPTION OF RISK 
  2. PARTICIPANT RELEASE OF LIABILITY, WAIVER OF CLAIMS, AND INDEMNITY AGREEMENT
  3. MEDICAL INFORMATION
  4. EMERGENCY CONTACT INFORMATION


1. ASSUMPTION OF RISK

Express Assumption of Risk Associated with Mountaineering, Climbing, Skiing, Snowboarding Biking, and Other Activities offered by Blackbird Mountain Guides, LLC.

In consideration of the services that Blackbird Mountain Guides, LLC, a California limited liability company, its agents, owners, members, managers, officers, volunteers, affiliates, participants, employees, and all other persons or entities acting in any capacity on their behalf (hereinafter, collectively referred to as “Blackbird Guides”). I do hereby affirm and acknowledge that I have been fully informed and understand the inherent hazards and risks associated with Alpine Mountaineering, Rock Climbing, Ice Climbing, Backcountry Ski/Snowboard Touring, Ski/Snowboard Mountaineering and Mountain Biking activities, transportation of equipment related to the activities, and traveling to and from activity sites in which I am about to engage. 

These risks include, but are not limited to: 

  1. Conditions that can make skiing, snowboarding, hiking, biking, or climbing difficult and dangerous and that may result in significant injury or death as a result of a fall or an impact with another object; these include, ski lifts and other ski area infrastructure and signage, steep slopes, ice, snow cornices, poor snow conditions, poor visibility, bad weather, low temperatures, extreme heat, sun exposure, trees, tree-wells, rocks, creeks, boulders, holes, depressions and other obstacles that may be below the snow surface, deep snow and other backcountry users, including those that may be untrained and making poor decisions.   
  2. Risks related to environmental conditions, such as cold weather and heat related injuries and illness including but not limited to frostnip, frostbite, heat exhaustion, heat stroke, sunburn, hypothermia and dehydration, or food or water-borne illness.
  3. Risks related to outdoor elements, including but not limited to avalanches, rock fall, inclement weather, thunder and lighting, severe and or varied wind, temperature or weather conditions. 
  4. Risk of injury from the equipment utilized the activities guided by Blackbird Guides, such as ski retention systems not functioning properly, boots that malfunction, crampons which do not stay in place, which combined with other factors can result in significant injury or death. 
  5. Risks associated with mechanized access to skiing or climbing, including helicopters, snowcats and ski area infrastructure, such as chair lifts, lift towers, ski area signage, snow grooming equipment, snow making equipment.
  6. Risks associated with lodging, including hotels, backcountry lodges, yurts, huts, etc and the associated grounds and facilities.
  7. Injury or death may be caused by my own negligence and/or the negligence of others, including employees, agents, independent contractors or representatives of Blackbird Guides. Blackbird Guides may make mistakes in judgment, be unaware of a participant’s fitness or abilities, misjudge the weather or other avalanche conditions, or give incomplete or confusing warnings and instructions.
  8. Injuries may occur from exposure to high altitude, which may affect judgment and coordination, may cause altitude sickness, including high altitude pulmonary edema and high-altitude cerebral edema, which may be irreversible and cause death.
  9. Risks of injury or death as a result of attacks by or encounters with insects, reptiles, including snakes, and/or animals, such as bears, mountain goats, mountain lions, or others.
  10. Risks associated with infectious disease which may be caused by Blackbird Guides or other participants, including the risk of infection from COVID-19 or other diseases, which may be more prevalent due to the nature of common cooking or sleeping arrangements in wilderness settings. 
  11. In addition, due to the remote nature of many operating areas, evacuation to definitive medical care may be difficult or impossible. As a result, there is a risk that medical or other emergencies may be difficult or impossible to effectively handle, increasing the risk of more substantial injury or death, than might occur if such an emergency occurred in an urban setting.

I understand the description of these risks is not complete and that unknown or unanticipated risks may result in injury, illness, or death.

I expressly agree and promise to accept and assume all of the risks existing in this activity. My participation in this activity is purely voluntary, and I elect to participate in spite of the risks.


                                                                                

Signature of Adult Participant  


2. RELEASE OF LIABILITY, WAIVER OF CLAIMS, AND INDEMNITY AGREEMENT.

Please read carefully and be certain you understand the implications of signing as you are agreeing to waive certain rights.

  1. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Blackbird Guides, and its owners, members, managers, employees, agents, volunteers, contractors, guides, participants and all other persons or entities acting in any capacity on their behalf, from any and all claims, demands, or causes of action, which are in any way connected with or related to my participation in this activity or my use of Blackbird Guides’ equipment or facilities, including any such claims which allege negligent acts or omissions of Blackbird Guides.
  2. To the extent that Blackbird Guides or anyone acting on their behalf be required to incur attorney’s fees and costs to enforce this agreement or defend any claim by you that has been released pursuant to the terms of this agreement, I agree to indemnify and hold them harmless for all such fees and costs (including reasonable attorney’s fees).
  3. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else I agree to bear the costs of such injury or damage myself. I further certify that I am willing to assume the risk of any medical or physical condition I may have.
  4. In the event that I file a lawsuit against Blackbird Guides, I hereby agree to do so solely in the state of California, and I further agree that the substantive law of California shall apply in that action without regard to the conflict of law rules of that state. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.
  5. I understand that the Activities may occur on lands owned by the United States Government, Foreign Governments, State or Local Governments or Private Landowners (together, the “Landowners”), but that the Landowners are not responsible for my safety in any way and have warned that there are hazards on their lands (both natural and man-made) which may hidden and not obvious and which may include, but are not limited to cliffs, crevasses, avalanche and other dangers. I hereby agree to release, indemnify, and discharge the Landowners, on behalf of myself, my spouse, my children, my parents, my heirs, assigns, personal representative and estate from and against any and all claims which relate to or may grow out of my participation in helicopter, snowcat, backcountry skiing, ski mountaineering, alpine mountaineering, rock climbing, ice climbing or other activities administered by Blackbird Guides. 

By signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in this activity, I will likely be found by a court of law to have waived my right to maintain a lawsuit against Blackbird Guides on the basis of any claim from which I have released them herein.

I HAVE READ THIS RELEASE OF LIABILITY, WAIVER OF CLAIMS, AND INDEMNITY AGREEMENT, AND I FULLY UNDERSTAND ITS TERMS.

I UNDERSTAND THAT I HAVE GIVEN UP LEGAL RIGHTS BY SIGNING IT, AND I SIGN IT FREELY AND VOLUNTARILY, WITHOUT ANY INDUCEMENT, AND AGREE TO BE BOUND BY ITS TERMS.

 

                                                                                

Signature of Adult Participant            

The RELEASE OF LIABILITY, WAIVER OF CLAIMS, AND INDEMNITY AGREEMENT section of this agreement will not apply to programs that do not allow for the use of a waiver, including programs operated on US National Park Service (NPS) lands. All other portions of this document apply.

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Please choose the name of the program that you will be participating in:*

If you selected OTHER please type in the name of the program here.

Please add the date of the first FIELD day of your program: *

Medical Information

Please complete the information below to provide an understanding of your medical history.



Age *

Weight in pounds (ex: 175) *

Height (Feet, Inches Ex: 5'10") *

Describe your current level of health. (i.e. generally healthy, chronic joint pain, etc...)

Describe your current physical fitness and level of activity. (i.e. excellent shape, run 1 hour per day, weights two hours per week, etc.)
Check the box if you CURRENTLY HAVE or HAVE a history of:
Hypertension
Heart attack or heart disease
Heart palpitations or murmur
Chest pain/pressure
Stroke
Smoking
Diabetes
Respiratory Problems
Gastrointestinal Concerns
Genitourinary concerns
Bleeding or blood disorders
Infectious disease
Neurologic problems, seizures
Dizziness or fainting
Mental health concerns
Recent illnesses
Joint or extremity pain/injury
Spine pain or injury
Dietary restrictions
Eating disorder
Major surgery
Physical disability
Are you currently under the care of a medical professional?
Are you pregnant?
Allergies?
Frostbite or cold injury?
Heat Injury
Altitude illness
Are you currently using or carrying any medications?

IF YOU SELECTED ANY OF THE CONDITIONS ABOVE, please describe the condition(s) here in detail.
Do you have any other health concerns?*
No
Yes

IF YOU DO HAVE OTHER HEALTH CONCERNS, please describe them here. (If you have none, please leave this field blank.)

Emergency Contact Info


Emergency Contact Name (First Name Last Name) *

Emergency Contact Phone Number (xxx) xxx-xxxx *

Emergency Contact Email *

Relationship to You
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Please choose the name of the program that you will be participating in:*

If you selected OTHER please type in the name of the program here.

Please add the date of the first FIELD day of your program: *

Medical Information

Please complete the information below to provide an understanding of your medical history.



Age *

Weight in pounds (ex: 175) *

Height (Feet, Inches Ex: 5'10") *

Describe your current level of health. (i.e. generally healthy, chronic joint pain, etc...)

Describe your current physical fitness and level of activity. (i.e. excellent shape, run 1 hour per day, weights two hours per week, etc.)
Check the box if you CURRENTLY HAVE or HAVE a history of:
Hypertension
Heart attack or heart disease
Heart palpitations or murmur
Chest pain/pressure
Stroke
Smoking
Diabetes
Respiratory Problems
Gastrointestinal Concerns
Genitourinary concerns
Bleeding or blood disorders
Infectious disease
Neurologic problems, seizures
Dizziness or fainting
Mental health concerns
Recent illnesses
Joint or extremity pain/injury
Spine pain or injury
Dietary restrictions
Eating disorder
Major surgery
Physical disability
Are you currently under the care of a medical professional?
Are you pregnant?
Allergies?
Frostbite or cold injury?
Heat Injury
Altitude illness
Are you currently using or carrying any medications?

IF YOU SELECTED ANY OF THE CONDITIONS ABOVE, please describe the condition(s) here in detail.
Do you have any other health concerns?*
No
Yes

IF YOU DO HAVE OTHER HEALTH CONCERNS, please describe them here. (If you have none, please leave this field blank.)

Emergency Contact Info


Emergency Contact Name (First Name Last Name) *

Emergency Contact Phone Number (xxx) xxx-xxxx *

Emergency Contact Email *

Relationship to You
Second Participant's Signature*
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Please choose the name of the program that you will be participating in:*

If you selected OTHER please type in the name of the program here.

Please add the date of the first FIELD day of your program: *

Medical Information

Please complete the information below to provide an understanding of your medical history.



Age *

Weight in pounds (ex: 175) *

Height (Feet, Inches Ex: 5'10") *

Describe your current level of health. (i.e. generally healthy, chronic joint pain, etc...)

Describe your current physical fitness and level of activity. (i.e. excellent shape, run 1 hour per day, weights two hours per week, etc.)
Check the box if you CURRENTLY HAVE or HAVE a history of:
Hypertension
Heart attack or heart disease
Heart palpitations or murmur
Chest pain/pressure
Stroke
Smoking
Diabetes
Respiratory Problems
Gastrointestinal Concerns
Genitourinary concerns
Bleeding or blood disorders
Infectious disease
Neurologic problems, seizures
Dizziness or fainting
Mental health concerns
Recent illnesses
Joint or extremity pain/injury
Spine pain or injury
Dietary restrictions
Eating disorder
Major surgery
Physical disability
Are you currently under the care of a medical professional?
Are you pregnant?
Allergies?
Frostbite or cold injury?
Heat Injury
Altitude illness
Are you currently using or carrying any medications?

IF YOU SELECTED ANY OF THE CONDITIONS ABOVE, please describe the condition(s) here in detail.
Do you have any other health concerns?*
No
Yes

IF YOU DO HAVE OTHER HEALTH CONCERNS, please describe them here. (If you have none, please leave this field blank.)

Emergency Contact Info


Emergency Contact Name (First Name Last Name) *

Emergency Contact Phone Number (xxx) xxx-xxxx *

Emergency Contact Email *

Relationship to You
Third Participant's Signature*
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Please choose the name of the program that you will be participating in:*

If you selected OTHER please type in the name of the program here.

Please add the date of the first FIELD day of your program: *

Medical Information

Please complete the information below to provide an understanding of your medical history.



Age *

Weight in pounds (ex: 175) *

Height (Feet, Inches Ex: 5'10") *

Describe your current level of health. (i.e. generally healthy, chronic joint pain, etc...)

Describe your current physical fitness and level of activity. (i.e. excellent shape, run 1 hour per day, weights two hours per week, etc.)
Check the box if you CURRENTLY HAVE or HAVE a history of:
Hypertension
Heart attack or heart disease
Heart palpitations or murmur
Chest pain/pressure
Stroke
Smoking
Diabetes
Respiratory Problems
Gastrointestinal Concerns
Genitourinary concerns
Bleeding or blood disorders
Infectious disease
Neurologic problems, seizures
Dizziness or fainting
Mental health concerns
Recent illnesses
Joint or extremity pain/injury
Spine pain or injury
Dietary restrictions
Eating disorder
Major surgery
Physical disability
Are you currently under the care of a medical professional?
Are you pregnant?
Allergies?
Frostbite or cold injury?
Heat Injury
Altitude illness
Are you currently using or carrying any medications?

IF YOU SELECTED ANY OF THE CONDITIONS ABOVE, please describe the condition(s) here in detail.
Do you have any other health concerns?*
No
Yes

IF YOU DO HAVE OTHER HEALTH CONCERNS, please describe them here. (If you have none, please leave this field blank.)

Emergency Contact Info


Emergency Contact Name (First Name Last Name) *

Emergency Contact Phone Number (xxx) xxx-xxxx *

Emergency Contact Email *

Relationship to You
Fourth Participant's Signature*
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Please choose the name of the program that you will be participating in:*

If you selected OTHER please type in the name of the program here.

Please add the date of the first FIELD day of your program: *

Medical Information

Please complete the information below to provide an understanding of your medical history.



Age *

Weight in pounds (ex: 175) *

Height (Feet, Inches Ex: 5'10") *

Describe your current level of health. (i.e. generally healthy, chronic joint pain, etc...)

Describe your current physical fitness and level of activity. (i.e. excellent shape, run 1 hour per day, weights two hours per week, etc.)
Check the box if you CURRENTLY HAVE or HAVE a history of:
Hypertension
Heart attack or heart disease
Heart palpitations or murmur
Chest pain/pressure
Stroke
Smoking
Diabetes
Respiratory Problems
Gastrointestinal Concerns
Genitourinary concerns
Bleeding or blood disorders
Infectious disease
Neurologic problems, seizures
Dizziness or fainting
Mental health concerns
Recent illnesses
Joint or extremity pain/injury
Spine pain or injury
Dietary restrictions
Eating disorder
Major surgery
Physical disability
Are you currently under the care of a medical professional?
Are you pregnant?
Allergies?
Frostbite or cold injury?
Heat Injury
Altitude illness
Are you currently using or carrying any medications?

IF YOU SELECTED ANY OF THE CONDITIONS ABOVE, please describe the condition(s) here in detail.
Do you have any other health concerns?*
No
Yes

IF YOU DO HAVE OTHER HEALTH CONCERNS, please describe them here. (If you have none, please leave this field blank.)

Emergency Contact Info


Emergency Contact Name (First Name Last Name) *

Emergency Contact Phone Number (xxx) xxx-xxxx *

Emergency Contact Email *

Relationship to You
Fifth Participant's Signature*
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Please choose the name of the program that you will be participating in:*

If you selected OTHER please type in the name of the program here.

Please add the date of the first FIELD day of your program: *

Medical Information

Please complete the information below to provide an understanding of your medical history.



Age *

Weight in pounds (ex: 175) *

Height (Feet, Inches Ex: 5'10") *

Describe your current level of health. (i.e. generally healthy, chronic joint pain, etc...)

Describe your current physical fitness and level of activity. (i.e. excellent shape, run 1 hour per day, weights two hours per week, etc.)
Check the box if you CURRENTLY HAVE or HAVE a history of:
Hypertension
Heart attack or heart disease
Heart palpitations or murmur
Chest pain/pressure
Stroke
Smoking
Diabetes
Respiratory Problems
Gastrointestinal Concerns
Genitourinary concerns
Bleeding or blood disorders
Infectious disease
Neurologic problems, seizures
Dizziness or fainting
Mental health concerns
Recent illnesses
Joint or extremity pain/injury
Spine pain or injury
Dietary restrictions
Eating disorder
Major surgery
Physical disability
Are you currently under the care of a medical professional?
Are you pregnant?
Allergies?
Frostbite or cold injury?
Heat Injury
Altitude illness
Are you currently using or carrying any medications?

IF YOU SELECTED ANY OF THE CONDITIONS ABOVE, please describe the condition(s) here in detail.
Do you have any other health concerns?*
No
Yes

IF YOU DO HAVE OTHER HEALTH CONCERNS, please describe them here. (If you have none, please leave this field blank.)

Emergency Contact Info


Emergency Contact Name (First Name Last Name) *

Emergency Contact Phone Number (xxx) xxx-xxxx *

Emergency Contact Email *

Relationship to You
Sixth Participant's Signature*
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Please choose the name of the program that you will be participating in:*

If you selected OTHER please type in the name of the program here.

Please add the date of the first FIELD day of your program: *

Medical Information

Please complete the information below to provide an understanding of your medical history.



Age *

Weight in pounds (ex: 175) *

Height (Feet, Inches Ex: 5'10") *

Describe your current level of health. (i.e. generally healthy, chronic joint pain, etc...)

Describe your current physical fitness and level of activity. (i.e. excellent shape, run 1 hour per day, weights two hours per week, etc.)
Check the box if you CURRENTLY HAVE or HAVE a history of:
Hypertension
Heart attack or heart disease
Heart palpitations or murmur
Chest pain/pressure
Stroke
Smoking
Diabetes
Respiratory Problems
Gastrointestinal Concerns
Genitourinary concerns
Bleeding or blood disorders
Infectious disease
Neurologic problems, seizures
Dizziness or fainting
Mental health concerns
Recent illnesses
Joint or extremity pain/injury
Spine pain or injury
Dietary restrictions
Eating disorder
Major surgery
Physical disability
Are you currently under the care of a medical professional?
Are you pregnant?
Allergies?
Frostbite or cold injury?
Heat Injury
Altitude illness
Are you currently using or carrying any medications?

IF YOU SELECTED ANY OF THE CONDITIONS ABOVE, please describe the condition(s) here in detail.
Do you have any other health concerns?*
No
Yes

IF YOU DO HAVE OTHER HEALTH CONCERNS, please describe them here. (If you have none, please leave this field blank.)

Emergency Contact Info


Emergency Contact Name (First Name Last Name) *

Emergency Contact Phone Number (xxx) xxx-xxxx *

Emergency Contact Email *

Relationship to You
Seventh Participant's Signature*
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Please choose the name of the program that you will be participating in:*

If you selected OTHER please type in the name of the program here.

Please add the date of the first FIELD day of your program: *

Medical Information

Please complete the information below to provide an understanding of your medical history.



Age *

Weight in pounds (ex: 175) *

Height (Feet, Inches Ex: 5'10") *

Describe your current level of health. (i.e. generally healthy, chronic joint pain, etc...)

Describe your current physical fitness and level of activity. (i.e. excellent shape, run 1 hour per day, weights two hours per week, etc.)
Check the box if you CURRENTLY HAVE or HAVE a history of:
Hypertension
Heart attack or heart disease
Heart palpitations or murmur
Chest pain/pressure
Stroke
Smoking
Diabetes
Respiratory Problems
Gastrointestinal Concerns
Genitourinary concerns
Bleeding or blood disorders
Infectious disease
Neurologic problems, seizures
Dizziness or fainting
Mental health concerns
Recent illnesses
Joint or extremity pain/injury
Spine pain or injury
Dietary restrictions
Eating disorder
Major surgery
Physical disability
Are you currently under the care of a medical professional?
Are you pregnant?
Allergies?
Frostbite or cold injury?
Heat Injury
Altitude illness
Are you currently using or carrying any medications?

IF YOU SELECTED ANY OF THE CONDITIONS ABOVE, please describe the condition(s) here in detail.
Do you have any other health concerns?*
No
Yes

IF YOU DO HAVE OTHER HEALTH CONCERNS, please describe them here. (If you have none, please leave this field blank.)

Emergency Contact Info


Emergency Contact Name (First Name Last Name) *

Emergency Contact Phone Number (xxx) xxx-xxxx *

Emergency Contact Email *

Relationship to You
Eighth Participant's Signature*
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Please choose the name of the program that you will be participating in:*

If you selected OTHER please type in the name of the program here.

Please add the date of the first FIELD day of your program: *

Medical Information

Please complete the information below to provide an understanding of your medical history.



Age *

Weight in pounds (ex: 175) *

Height (Feet, Inches Ex: 5'10") *

Describe your current level of health. (i.e. generally healthy, chronic joint pain, etc...)

Describe your current physical fitness and level of activity. (i.e. excellent shape, run 1 hour per day, weights two hours per week, etc.)
Check the box if you CURRENTLY HAVE or HAVE a history of:
Hypertension
Heart attack or heart disease
Heart palpitations or murmur
Chest pain/pressure
Stroke
Smoking
Diabetes
Respiratory Problems
Gastrointestinal Concerns
Genitourinary concerns
Bleeding or blood disorders
Infectious disease
Neurologic problems, seizures
Dizziness or fainting
Mental health concerns
Recent illnesses
Joint or extremity pain/injury
Spine pain or injury
Dietary restrictions
Eating disorder
Major surgery
Physical disability
Are you currently under the care of a medical professional?
Are you pregnant?
Allergies?
Frostbite or cold injury?
Heat Injury
Altitude illness
Are you currently using or carrying any medications?

IF YOU SELECTED ANY OF THE CONDITIONS ABOVE, please describe the condition(s) here in detail.
Do you have any other health concerns?*
No
Yes

IF YOU DO HAVE OTHER HEALTH CONCERNS, please describe them here. (If you have none, please leave this field blank.)

Emergency Contact Info


Emergency Contact Name (First Name Last Name) *

Emergency Contact Phone Number (xxx) xxx-xxxx *

Emergency Contact Email *

Relationship to You
Ninth Participant's Signature*
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Please choose the name of the program that you will be participating in:*

If you selected OTHER please type in the name of the program here.

Please add the date of the first FIELD day of your program: *

Medical Information

Please complete the information below to provide an understanding of your medical history.



Age *

Weight in pounds (ex: 175) *

Height (Feet, Inches Ex: 5'10") *

Describe your current level of health. (i.e. generally healthy, chronic joint pain, etc...)

Describe your current physical fitness and level of activity. (i.e. excellent shape, run 1 hour per day, weights two hours per week, etc.)
Check the box if you CURRENTLY HAVE or HAVE a history of:
Hypertension
Heart attack or heart disease
Heart palpitations or murmur
Chest pain/pressure
Stroke
Smoking
Diabetes
Respiratory Problems
Gastrointestinal Concerns
Genitourinary concerns
Bleeding or blood disorders
Infectious disease
Neurologic problems, seizures
Dizziness or fainting
Mental health concerns
Recent illnesses
Joint or extremity pain/injury
Spine pain or injury
Dietary restrictions
Eating disorder
Major surgery
Physical disability
Are you currently under the care of a medical professional?
Are you pregnant?
Allergies?
Frostbite or cold injury?
Heat Injury
Altitude illness
Are you currently using or carrying any medications?

IF YOU SELECTED ANY OF THE CONDITIONS ABOVE, please describe the condition(s) here in detail.
Do you have any other health concerns?*
No
Yes

IF YOU DO HAVE OTHER HEALTH CONCERNS, please describe them here. (If you have none, please leave this field blank.)

Emergency Contact Info


Emergency Contact Name (First Name Last Name) *

Emergency Contact Phone Number (xxx) xxx-xxxx *

Emergency Contact Email *

Relationship to You
Tenth Participant's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
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*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Please choose the name of the program that you will be participating in:*

If you selected OTHER please type in the name of the program here.

Please add the date of the first FIELD day of your program: *

Medical Information

Please complete the information below to provide an understanding of your medical history.



Age *

Weight in pounds (ex: 175) *

Height (Feet, Inches Ex: 5'10") *

Describe your current level of health. (i.e. generally healthy, chronic joint pain, etc...)

Describe your current physical fitness and level of activity. (i.e. excellent shape, run 1 hour per day, weights two hours per week, etc.)
Check the box if you CURRENTLY HAVE or HAVE a history of:
Hypertension
Heart attack or heart disease
Heart palpitations or murmur
Chest pain/pressure
Stroke
Smoking
Diabetes
Respiratory Problems
Gastrointestinal Concerns
Genitourinary concerns
Bleeding or blood disorders
Infectious disease
Neurologic problems, seizures
Dizziness or fainting
Mental health concerns
Recent illnesses
Joint or extremity pain/injury
Spine pain or injury
Dietary restrictions
Eating disorder
Major surgery
Physical disability
Are you currently under the care of a medical professional?
Are you pregnant?
Allergies?
Frostbite or cold injury?
Heat Injury
Altitude illness
Are you currently using or carrying any medications?

IF YOU SELECTED ANY OF THE CONDITIONS ABOVE, please describe the condition(s) here in detail.
Do you have any other health concerns?*
No
Yes

IF YOU DO HAVE OTHER HEALTH CONCERNS, please describe them here. (If you have none, please leave this field blank.)

Emergency Contact Info


Emergency Contact Name (First Name Last Name) *

Emergency Contact Phone Number (xxx) xxx-xxxx *

Emergency Contact Email *

Relationship to You
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.


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