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Colorado Adventure Guides

I (Client), hereby acknowledge that I have voluntarily chosen to participate in the activities of backcountry safety education, avalanche education, backcountry skiing, backcountry snowboarding, snowshoeing, cross-country skiing, telemark skiing, hiking, backpacking, bicycling, rock climbing, mountaineering, and/or orienteering with equipment and/or activities and services provided by CAG Operations, LLC, dba Colorado Adventure Guides (any one, or combination of or all of which are referred to herein as the “OUTFITTER”),

1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular skills, equipment and personal discipline may reduce this risk, the risk of serious injury does exist; and,

2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation.

3. I willingly agree to comply with the stated and customary terms and conditions. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the Company immediately; and,

4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY AND HOLD HARMLESS OUTFITTER , their officers, shareholders, managers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises or equipment used for the activity (“Releasees”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property associated with my presence or participation, whether arising from the negligence of the Releasees or otherwise, to the fullest extent permitted by law.

I understand and agree that any bodily injury, death or loss of personal property and any expenses thereof as a result of my negligence, of my family or minor children participating in any scheduled or unscheduled activities as contemplated herein are my responsibility.

I understand and agree that the activities of backcountry safety education, avalanche education, backcountry skiing, backcountry snowboarding, snowshoeing, cross-country skiing, telemark skiing, hiking, backpacking, bicycling, rock climbing, mountaineering, and/or orienteering involve numerous risks of injury and possible death that are my responsibility and I fully assume these risks, including but not limited to loss of control, collisions and/or obstacles whether they are obvious or not. I and/or my family also understand that bicycles, snowshoes, skis, harnesses, and all other equipment, irrespective of regular maintenance, stand the chance of malfunction, which is an inherent risk to be assumed by each participant in the aforementioned activities, and I agree to assume that risk.

I understand that I may encounter variations in terrain and weather that are my responsibility and I assume these risks including but not limited to creeks, water bridges, traveled and un-traveled roads, marked and unmarked trails, wild animals, stumps, forest growth, debris, rocks, cliffs, Acts of God and other obstacles whether they are obvious or not, man-made or natural.

I understand that I am solely responsible for any and all bodily injury, death or loss of property and any expense thereof as a result of traveling to, from, or between scheduled or unscheduled activities contemplated hereby or connection with any activity or function of Outfitter, whether or not such transportation is provide by me or by Releasees.

I understand and agree that any route or activity, chosen as a part of the sport in which I and/or my family am/are participating may not be the safest but has or will be chosen for its interest, challenge, or best meeting the goals or the services for which I am contracting.

I understand that the activities that I am participating in may be photographed or video recorded solely for releasees’ promotional purposes.

AS LAWFUL CONSIDERATION FOR BEING PERMITTED BY OUTFITTER TO PARTICIPATE IN THE ACTIVITIES OF BACKCOUNTRY SAFETY EDUCATION, AVALANCHE EDUCATION, BACKCOUNTRY SKIING, BACKCOUNTRY SNOWBOARDING, SNOWSHOEING, CROSS-COUNTRY SKIING, TELEMARK SKIING, HIKING, BACKPACKING, BICYCLING, ROCK CLIMBING, MOUNTAINEERING, AND/OR ORIENTEERING, I DO HEREBY RELEASE FROM ANY LEGAL LIABILITY, AGREE NOT TO SUE, CLAIM AGAINST, ATTACH THE PROPERTY OF OR PERSECUTE, AND FURTHER AGREE TO DEFEND, INDEMNIFY AND HOLD HARMLESS THE OUTFITTER, INCLUDING ANY OF ITS EMPLOYEES, OWNERS, CONTRACTORS, AGENTS, CAG OPERATIONS, LLC, COLORADO ADVENTURE GUIDES, TOWN OF BRECKENRIDGE AND THE UNITED STATES FOREST SERVICE, FOR ANY INJURY OR DEATH CAUSED BY OR RESULTING FROM MY PARTICIPATION IN THE ACTIVITIES DESCRIBED ABOVE, WHETHER OR NOT SUCH INJURY OR DEATH WAS CAUSED BY THEIR NEGLIGENCE OR FROM ANY OTHER CAUSE.

This contract shall be legally binding upon me, my heirs, my assigns, my legal guardians and my personal representatives. I have carefully read this agreement and fully and completely understand its contents. I am aware that I am releasing certain legal rights that I, my family, or my minor children may otherwise have, and I enter into this contract in behalf of myself and/or my family or minor children voluntarily and of my own free will.

NOTICE: THIS IS A RELEASE OF LIABILITY. DO NOT SIGN OR INITIAL THE RELEASE IF YOU DO NOT UNDERSTAND OR DO NOT AGREE WITH ITS TERMS. IF UNDER EIGHTEEN (18) YEARS OF AGE, SIGNATURE OF PARENT OR GUARDIAN IS ALSO REQUIRED. I HAVE READ THIS RELEASE OF LIABILITY, AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT

Today's Date: September 25, 2020

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Health History Form 

Colorado Adventure Guides' trips may be half-day, full-day, or multi-day wilderness expeditions in remote settings, where evacuation to modern hospital facilities is not immediately possible. You must expect extreme weather conditions ranging from snow storms to sleet to extreme heat. Sudden environmental changes are to be expected and anticipated. Depending on what activity you pursue with Colorado Adventure Guides you may be required to walk for several hours; carry a heavy load up uneven, steep terrain; sleep outdoors; experience long, tough days; and prepare meals and set up camp. If you have any questions about the activity and your participation, you may contact Colorado Adventure Guides directly.

Participant: Please circle YES or NO for each question. Each must be answered, but keep in mind that a "YES" answer does not necessarily mean you will not be able to participate. If you answer "YES" to any question, you may be asked to discuss your condition with the guide before departing. Guides reserve the right to make a decision on a participant's eligibility at any time. 

Do you currently have or have a history of: 

1. Respiratory problems? Asthma?*
No
Yes
2. Gastrointestinal disturbances?*
No
Yes
3. Diabetes or Hypoglycemia?*
No
Yes
4. Hypertension?*
No
Yes
5. Bleeding or blood disorders?*
No
Yes
6. Hepatitis or other liver diseases?*
No
Yes
7. Epilepsy? Seizures?*
No
Yes
8. Dizziness or fainting episodes?*
No
Yes
9. Treatment or medication for menstrual cramps?*
No
Yes
10. Disorders of the urinary or reproductive tract?*
No
Yes
11. Do you see a Medical/Physical specialist of any kind?*
No
Yes
12. Are you pregnant?*
No
Yes
13. Treatment or counseling with a mental health professional?*
No
Yes
14. Cardiac problems?*
No
Yes
15. Anorexia/Bulimia/Eating Disorder?*
No
Yes
16. Heatstroke/Heat Exhaustion?*
No
Yes
17. Physical or Sensory Limitation?*
No
Yes
18. Any other health complaint?*
No
Yes

If you chose "YES" on any of the questions, 1-18, please provide a brief description of your condition and any associated physical limitations:

Musculoskeletal Injuries
Do you currently have or have a history of: 


19. Knee, hip, ankle, shoulder, arm, back, or other injuries to muscles, tendons, ligaments, or bones sprains)? If so, please explain:

20. Have any of these injuries required surgery? If so, please explain:

Allergies/Medications 

21. Do you have any allergies? (including insect bites or bee stings)*
No
Yes

please list them, along with their severity and current treatment plan
22. Are you allergic to any medications?*
No
Yes
23. Are you currently taking any medications?*
No
Yes

Medication dosage/schedule
24. Have you ever been treated for any altitude related illness?*
No
Yes
25. Have you ever been treated for frostbite or other cold related injury/illness?*
No
Yes
26. Have your ever been treated for heat stroke or other heat related illness?*
No
Yes

Do you have any other physical, medical, or psychological conditions not listed above?
27. Do you exercise regularly?*
No
Yes

How often?

Restrictions

Duration/Distance

Intensity Level (easy/moderate/competitive)
28. Do you smoke?*
No
Yes

If so, how much?
29. Swimming ability*

Diet 


30. Do you have any dietary restrictions or food allergies? If yes, please describe (Are you vegetarian, vegan, gluten---free, or lactose intolerant? How strict are you? If you have a food allergy, what happens when you are exposed to the allergen?)

PLEASE READ CAREFULLY AND SIGN

The information provided above is a complete and accurate statement of any physical and psychological conditions, which may affect my participation in this trip. I realize that failure to disclose such information could result in serious harm to me, fellow participants, the guide. I agree to inform Colorado Adventure Guides should there be any change in my health status prior to the start of the trip. On the basis of the background information at the beginning of this form, and what I know or suspect about my physical and psychological health, I am fully capable of participating in this activity. I understand that if I have the potential for a severe allergic reaction to bee stings, insect bites, food, poison oak, or other substances that might be found in the outdoors, it is my responsibility to carry the proper medication with me. 


Emergency Contact Name/Relationship: *

Emergency Contact Phone Number: *
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Health History Form 

Colorado Adventure Guides' trips may be half-day, full-day, or multi-day wilderness expeditions in remote settings, where evacuation to modern hospital facilities is not immediately possible. You must expect extreme weather conditions ranging from snow storms to sleet to extreme heat. Sudden environmental changes are to be expected and anticipated. Depending on what activity you pursue with Colorado Adventure Guides you may be required to walk for several hours; carry a heavy load up uneven, steep terrain; sleep outdoors; experience long, tough days; and prepare meals and set up camp. If you have any questions about the activity and your participation, you may contact Colorado Adventure Guides directly.

Participant: Please circle YES or NO for each question. Each must be answered, but keep in mind that a "YES" answer does not necessarily mean you will not be able to participate. If you answer "YES" to any question, you may be asked to discuss your condition with the guide before departing. Guides reserve the right to make a decision on a participant's eligibility at any time. 

Do you currently have or have a history of: 

1. Respiratory problems? Asthma?*
No
Yes
2. Gastrointestinal disturbances?*
No
Yes
3. Diabetes or Hypoglycemia?*
No
Yes
4. Hypertension?*
No
Yes
5. Bleeding or blood disorders?*
No
Yes
6. Hepatitis or other liver diseases?*
No
Yes
7. Epilepsy? Seizures?*
No
Yes
8. Dizziness or fainting episodes?*
No
Yes
9. Treatment or medication for menstrual cramps?*
No
Yes
10. Disorders of the urinary or reproductive tract?*
No
Yes
11. Do you see a Medical/Physical specialist of any kind?*
No
Yes
12. Are you pregnant?*
No
Yes
13. Treatment or counseling with a mental health professional?*
No
Yes
14. Cardiac problems?*
No
Yes
15. Anorexia/Bulimia/Eating Disorder?*
No
Yes
16. Heatstroke/Heat Exhaustion?*
No
Yes
17. Physical or Sensory Limitation?*
No
Yes
18. Any other health complaint?*
No
Yes

If you chose "YES" on any of the questions, 1-18, please provide a brief description of your condition and any associated physical limitations:

Musculoskeletal Injuries
Do you currently have or have a history of: 


19. Knee, hip, ankle, shoulder, arm, back, or other injuries to muscles, tendons, ligaments, or bones sprains)? If so, please explain:

20. Have any of these injuries required surgery? If so, please explain:

Allergies/Medications 

21. Do you have any allergies? (including insect bites or bee stings)*
No
Yes

please list them, along with their severity and current treatment plan
22. Are you allergic to any medications?*
No
Yes
23. Are you currently taking any medications?*
No
Yes

Medication dosage/schedule
24. Have you ever been treated for any altitude related illness?*
No
Yes
25. Have you ever been treated for frostbite or other cold related injury/illness?*
No
Yes
26. Have your ever been treated for heat stroke or other heat related illness?*
No
Yes

Do you have any other physical, medical, or psychological conditions not listed above?
27. Do you exercise regularly?*
No
Yes

How often?

Restrictions

Duration/Distance

Intensity Level (easy/moderate/competitive)
28. Do you smoke?*
No
Yes

If so, how much?
29. Swimming ability*

Diet 


30. Do you have any dietary restrictions or food allergies? If yes, please describe (Are you vegetarian, vegan, gluten---free, or lactose intolerant? How strict are you? If you have a food allergy, what happens when you are exposed to the allergen?)

PLEASE READ CAREFULLY AND SIGN

The information provided above is a complete and accurate statement of any physical and psychological conditions, which may affect my participation in this trip. I realize that failure to disclose such information could result in serious harm to me, fellow participants, the guide. I agree to inform Colorado Adventure Guides should there be any change in my health status prior to the start of the trip. On the basis of the background information at the beginning of this form, and what I know or suspect about my physical and psychological health, I am fully capable of participating in this activity. I understand that if I have the potential for a severe allergic reaction to bee stings, insect bites, food, poison oak, or other substances that might be found in the outdoors, it is my responsibility to carry the proper medication with me. 


Emergency Contact Name/Relationship: *

Emergency Contact Phone Number: *
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Health History Form 

Colorado Adventure Guides' trips may be half-day, full-day, or multi-day wilderness expeditions in remote settings, where evacuation to modern hospital facilities is not immediately possible. You must expect extreme weather conditions ranging from snow storms to sleet to extreme heat. Sudden environmental changes are to be expected and anticipated. Depending on what activity you pursue with Colorado Adventure Guides you may be required to walk for several hours; carry a heavy load up uneven, steep terrain; sleep outdoors; experience long, tough days; and prepare meals and set up camp. If you have any questions about the activity and your participation, you may contact Colorado Adventure Guides directly.

Participant: Please circle YES or NO for each question. Each must be answered, but keep in mind that a "YES" answer does not necessarily mean you will not be able to participate. If you answer "YES" to any question, you may be asked to discuss your condition with the guide before departing. Guides reserve the right to make a decision on a participant's eligibility at any time. 

Do you currently have or have a history of: 

1. Respiratory problems? Asthma?*
No
Yes
2. Gastrointestinal disturbances?*
No
Yes
3. Diabetes or Hypoglycemia?*
No
Yes
4. Hypertension?*
No
Yes
5. Bleeding or blood disorders?*
No
Yes
6. Hepatitis or other liver diseases?*
No
Yes
7. Epilepsy? Seizures?*
No
Yes
8. Dizziness or fainting episodes?*
No
Yes
9. Treatment or medication for menstrual cramps?*
No
Yes
10. Disorders of the urinary or reproductive tract?*
No
Yes
11. Do you see a Medical/Physical specialist of any kind?*
No
Yes
12. Are you pregnant?*
No
Yes
13. Treatment or counseling with a mental health professional?*
No
Yes
14. Cardiac problems?*
No
Yes
15. Anorexia/Bulimia/Eating Disorder?*
No
Yes
16. Heatstroke/Heat Exhaustion?*
No
Yes
17. Physical or Sensory Limitation?*
No
Yes
18. Any other health complaint?*
No
Yes

If you chose "YES" on any of the questions, 1-18, please provide a brief description of your condition and any associated physical limitations:

Musculoskeletal Injuries
Do you currently have or have a history of: 


19. Knee, hip, ankle, shoulder, arm, back, or other injuries to muscles, tendons, ligaments, or bones sprains)? If so, please explain:

20. Have any of these injuries required surgery? If so, please explain:

Allergies/Medications 

21. Do you have any allergies? (including insect bites or bee stings)*
No
Yes

please list them, along with their severity and current treatment plan
22. Are you allergic to any medications?*
No
Yes
23. Are you currently taking any medications?*
No
Yes

Medication dosage/schedule
24. Have you ever been treated for any altitude related illness?*
No
Yes
25. Have you ever been treated for frostbite or other cold related injury/illness?*
No
Yes
26. Have your ever been treated for heat stroke or other heat related illness?*
No
Yes

Do you have any other physical, medical, or psychological conditions not listed above?
27. Do you exercise regularly?*
No
Yes

How often?

Restrictions

Duration/Distance

Intensity Level (easy/moderate/competitive)
28. Do you smoke?*
No
Yes

If so, how much?
29. Swimming ability*

Diet 


30. Do you have any dietary restrictions or food allergies? If yes, please describe (Are you vegetarian, vegan, gluten---free, or lactose intolerant? How strict are you? If you have a food allergy, what happens when you are exposed to the allergen?)

PLEASE READ CAREFULLY AND SIGN

The information provided above is a complete and accurate statement of any physical and psychological conditions, which may affect my participation in this trip. I realize that failure to disclose such information could result in serious harm to me, fellow participants, the guide. I agree to inform Colorado Adventure Guides should there be any change in my health status prior to the start of the trip. On the basis of the background information at the beginning of this form, and what I know or suspect about my physical and psychological health, I am fully capable of participating in this activity. I understand that if I have the potential for a severe allergic reaction to bee stings, insect bites, food, poison oak, or other substances that might be found in the outdoors, it is my responsibility to carry the proper medication with me. 


Emergency Contact Name/Relationship: *

Emergency Contact Phone Number: *
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Health History Form 

Colorado Adventure Guides' trips may be half-day, full-day, or multi-day wilderness expeditions in remote settings, where evacuation to modern hospital facilities is not immediately possible. You must expect extreme weather conditions ranging from snow storms to sleet to extreme heat. Sudden environmental changes are to be expected and anticipated. Depending on what activity you pursue with Colorado Adventure Guides you may be required to walk for several hours; carry a heavy load up uneven, steep terrain; sleep outdoors; experience long, tough days; and prepare meals and set up camp. If you have any questions about the activity and your participation, you may contact Colorado Adventure Guides directly.

Participant: Please circle YES or NO for each question. Each must be answered, but keep in mind that a "YES" answer does not necessarily mean you will not be able to participate. If you answer "YES" to any question, you may be asked to discuss your condition with the guide before departing. Guides reserve the right to make a decision on a participant's eligibility at any time. 

Do you currently have or have a history of: 

1. Respiratory problems? Asthma?*
No
Yes
2. Gastrointestinal disturbances?*
No
Yes
3. Diabetes or Hypoglycemia?*
No
Yes
4. Hypertension?*
No
Yes
5. Bleeding or blood disorders?*
No
Yes
6. Hepatitis or other liver diseases?*
No
Yes
7. Epilepsy? Seizures?*
No
Yes
8. Dizziness or fainting episodes?*
No
Yes
9. Treatment or medication for menstrual cramps?*
No
Yes
10. Disorders of the urinary or reproductive tract?*
No
Yes
11. Do you see a Medical/Physical specialist of any kind?*
No
Yes
12. Are you pregnant?*
No
Yes
13. Treatment or counseling with a mental health professional?*
No
Yes
14. Cardiac problems?*
No
Yes
15. Anorexia/Bulimia/Eating Disorder?*
No
Yes
16. Heatstroke/Heat Exhaustion?*
No
Yes
17. Physical or Sensory Limitation?*
No
Yes
18. Any other health complaint?*
No
Yes

If you chose "YES" on any of the questions, 1-18, please provide a brief description of your condition and any associated physical limitations:

Musculoskeletal Injuries
Do you currently have or have a history of: 


19. Knee, hip, ankle, shoulder, arm, back, or other injuries to muscles, tendons, ligaments, or bones sprains)? If so, please explain:

20. Have any of these injuries required surgery? If so, please explain:

Allergies/Medications 

21. Do you have any allergies? (including insect bites or bee stings)*
No
Yes

please list them, along with their severity and current treatment plan
22. Are you allergic to any medications?*
No
Yes
23. Are you currently taking any medications?*
No
Yes

Medication dosage/schedule
24. Have you ever been treated for any altitude related illness?*
No
Yes
25. Have you ever been treated for frostbite or other cold related injury/illness?*
No
Yes
26. Have your ever been treated for heat stroke or other heat related illness?*
No
Yes

Do you have any other physical, medical, or psychological conditions not listed above?
27. Do you exercise regularly?*
No
Yes

How often?

Restrictions

Duration/Distance

Intensity Level (easy/moderate/competitive)
28. Do you smoke?*
No
Yes

If so, how much?
29. Swimming ability*

Diet 


30. Do you have any dietary restrictions or food allergies? If yes, please describe (Are you vegetarian, vegan, gluten---free, or lactose intolerant? How strict are you? If you have a food allergy, what happens when you are exposed to the allergen?)

PLEASE READ CAREFULLY AND SIGN

The information provided above is a complete and accurate statement of any physical and psychological conditions, which may affect my participation in this trip. I realize that failure to disclose such information could result in serious harm to me, fellow participants, the guide. I agree to inform Colorado Adventure Guides should there be any change in my health status prior to the start of the trip. On the basis of the background information at the beginning of this form, and what I know or suspect about my physical and psychological health, I am fully capable of participating in this activity. I understand that if I have the potential for a severe allergic reaction to bee stings, insect bites, food, poison oak, or other substances that might be found in the outdoors, it is my responsibility to carry the proper medication with me. 


Emergency Contact Name/Relationship: *

Emergency Contact Phone Number: *
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Health History Form 

Colorado Adventure Guides' trips may be half-day, full-day, or multi-day wilderness expeditions in remote settings, where evacuation to modern hospital facilities is not immediately possible. You must expect extreme weather conditions ranging from snow storms to sleet to extreme heat. Sudden environmental changes are to be expected and anticipated. Depending on what activity you pursue with Colorado Adventure Guides you may be required to walk for several hours; carry a heavy load up uneven, steep terrain; sleep outdoors; experience long, tough days; and prepare meals and set up camp. If you have any questions about the activity and your participation, you may contact Colorado Adventure Guides directly.

Participant: Please circle YES or NO for each question. Each must be answered, but keep in mind that a "YES" answer does not necessarily mean you will not be able to participate. If you answer "YES" to any question, you may be asked to discuss your condition with the guide before departing. Guides reserve the right to make a decision on a participant's eligibility at any time. 

Do you currently have or have a history of: 

1. Respiratory problems? Asthma?*
No
Yes
2. Gastrointestinal disturbances?*
No
Yes
3. Diabetes or Hypoglycemia?*
No
Yes
4. Hypertension?*
No
Yes
5. Bleeding or blood disorders?*
No
Yes
6. Hepatitis or other liver diseases?*
No
Yes
7. Epilepsy? Seizures?*
No
Yes
8. Dizziness or fainting episodes?*
No
Yes
9. Treatment or medication for menstrual cramps?*
No
Yes
10. Disorders of the urinary or reproductive tract?*
No
Yes
11. Do you see a Medical/Physical specialist of any kind?*
No
Yes
12. Are you pregnant?*
No
Yes
13. Treatment or counseling with a mental health professional?*
No
Yes
14. Cardiac problems?*
No
Yes
15. Anorexia/Bulimia/Eating Disorder?*
No
Yes
16. Heatstroke/Heat Exhaustion?*
No
Yes
17. Physical or Sensory Limitation?*
No
Yes
18. Any other health complaint?*
No
Yes

If you chose "YES" on any of the questions, 1-18, please provide a brief description of your condition and any associated physical limitations:

Musculoskeletal Injuries
Do you currently have or have a history of: 


19. Knee, hip, ankle, shoulder, arm, back, or other injuries to muscles, tendons, ligaments, or bones sprains)? If so, please explain:

20. Have any of these injuries required surgery? If so, please explain:

Allergies/Medications 

21. Do you have any allergies? (including insect bites or bee stings)*
No
Yes

please list them, along with their severity and current treatment plan
22. Are you allergic to any medications?*
No
Yes
23. Are you currently taking any medications?*
No
Yes

Medication dosage/schedule
24. Have you ever been treated for any altitude related illness?*
No
Yes
25. Have you ever been treated for frostbite or other cold related injury/illness?*
No
Yes
26. Have your ever been treated for heat stroke or other heat related illness?*
No
Yes

Do you have any other physical, medical, or psychological conditions not listed above?
27. Do you exercise regularly?*
No
Yes

How often?

Restrictions

Duration/Distance

Intensity Level (easy/moderate/competitive)
28. Do you smoke?*
No
Yes

If so, how much?
29. Swimming ability*

Diet 


30. Do you have any dietary restrictions or food allergies? If yes, please describe (Are you vegetarian, vegan, gluten---free, or lactose intolerant? How strict are you? If you have a food allergy, what happens when you are exposed to the allergen?)

PLEASE READ CAREFULLY AND SIGN

The information provided above is a complete and accurate statement of any physical and psychological conditions, which may affect my participation in this trip. I realize that failure to disclose such information could result in serious harm to me, fellow participants, the guide. I agree to inform Colorado Adventure Guides should there be any change in my health status prior to the start of the trip. On the basis of the background information at the beginning of this form, and what I know or suspect about my physical and psychological health, I am fully capable of participating in this activity. I understand that if I have the potential for a severe allergic reaction to bee stings, insect bites, food, poison oak, or other substances that might be found in the outdoors, it is my responsibility to carry the proper medication with me. 


Emergency Contact Name/Relationship: *

Emergency Contact Phone Number: *
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Health History Form 

Colorado Adventure Guides' trips may be half-day, full-day, or multi-day wilderness expeditions in remote settings, where evacuation to modern hospital facilities is not immediately possible. You must expect extreme weather conditions ranging from snow storms to sleet to extreme heat. Sudden environmental changes are to be expected and anticipated. Depending on what activity you pursue with Colorado Adventure Guides you may be required to walk for several hours; carry a heavy load up uneven, steep terrain; sleep outdoors; experience long, tough days; and prepare meals and set up camp. If you have any questions about the activity and your participation, you may contact Colorado Adventure Guides directly.

Participant: Please circle YES or NO for each question. Each must be answered, but keep in mind that a "YES" answer does not necessarily mean you will not be able to participate. If you answer "YES" to any question, you may be asked to discuss your condition with the guide before departing. Guides reserve the right to make a decision on a participant's eligibility at any time. 

Do you currently have or have a history of: 

1. Respiratory problems? Asthma?*
No
Yes
2. Gastrointestinal disturbances?*
No
Yes
3. Diabetes or Hypoglycemia?*
No
Yes
4. Hypertension?*
No
Yes
5. Bleeding or blood disorders?*
No
Yes
6. Hepatitis or other liver diseases?*
No
Yes
7. Epilepsy? Seizures?*
No
Yes
8. Dizziness or fainting episodes?*
No
Yes
9. Treatment or medication for menstrual cramps?*
No
Yes
10. Disorders of the urinary or reproductive tract?*
No
Yes
11. Do you see a Medical/Physical specialist of any kind?*
No
Yes
12. Are you pregnant?*
No
Yes
13. Treatment or counseling with a mental health professional?*
No
Yes
14. Cardiac problems?*
No
Yes
15. Anorexia/Bulimia/Eating Disorder?*
No
Yes
16. Heatstroke/Heat Exhaustion?*
No
Yes
17. Physical or Sensory Limitation?*
No
Yes
18. Any other health complaint?*
No
Yes

If you chose "YES" on any of the questions, 1-18, please provide a brief description of your condition and any associated physical limitations:

Musculoskeletal Injuries
Do you currently have or have a history of: 


19. Knee, hip, ankle, shoulder, arm, back, or other injuries to muscles, tendons, ligaments, or bones sprains)? If so, please explain:

20. Have any of these injuries required surgery? If so, please explain:

Allergies/Medications 

21. Do you have any allergies? (including insect bites or bee stings)*
No
Yes

please list them, along with their severity and current treatment plan
22. Are you allergic to any medications?*
No
Yes
23. Are you currently taking any medications?*
No
Yes

Medication dosage/schedule
24. Have you ever been treated for any altitude related illness?*
No
Yes
25. Have you ever been treated for frostbite or other cold related injury/illness?*
No
Yes
26. Have your ever been treated for heat stroke or other heat related illness?*
No
Yes

Do you have any other physical, medical, or psychological conditions not listed above?
27. Do you exercise regularly?*
No
Yes

How often?

Restrictions

Duration/Distance

Intensity Level (easy/moderate/competitive)
28. Do you smoke?*
No
Yes

If so, how much?
29. Swimming ability*

Diet 


30. Do you have any dietary restrictions or food allergies? If yes, please describe (Are you vegetarian, vegan, gluten---free, or lactose intolerant? How strict are you? If you have a food allergy, what happens when you are exposed to the allergen?)

PLEASE READ CAREFULLY AND SIGN

The information provided above is a complete and accurate statement of any physical and psychological conditions, which may affect my participation in this trip. I realize that failure to disclose such information could result in serious harm to me, fellow participants, the guide. I agree to inform Colorado Adventure Guides should there be any change in my health status prior to the start of the trip. On the basis of the background information at the beginning of this form, and what I know or suspect about my physical and psychological health, I am fully capable of participating in this activity. I understand that if I have the potential for a severe allergic reaction to bee stings, insect bites, food, poison oak, or other substances that might be found in the outdoors, it is my responsibility to carry the proper medication with me. 


Emergency Contact Name/Relationship: *

Emergency Contact Phone Number: *
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Health History Form 

Colorado Adventure Guides' trips may be half-day, full-day, or multi-day wilderness expeditions in remote settings, where evacuation to modern hospital facilities is not immediately possible. You must expect extreme weather conditions ranging from snow storms to sleet to extreme heat. Sudden environmental changes are to be expected and anticipated. Depending on what activity you pursue with Colorado Adventure Guides you may be required to walk for several hours; carry a heavy load up uneven, steep terrain; sleep outdoors; experience long, tough days; and prepare meals and set up camp. If you have any questions about the activity and your participation, you may contact Colorado Adventure Guides directly.

Participant: Please circle YES or NO for each question. Each must be answered, but keep in mind that a "YES" answer does not necessarily mean you will not be able to participate. If you answer "YES" to any question, you may be asked to discuss your condition with the guide before departing. Guides reserve the right to make a decision on a participant's eligibility at any time. 

Do you currently have or have a history of: 

1. Respiratory problems? Asthma?*
No
Yes
2. Gastrointestinal disturbances?*
No
Yes
3. Diabetes or Hypoglycemia?*
No
Yes
4. Hypertension?*
No
Yes
5. Bleeding or blood disorders?*
No
Yes
6. Hepatitis or other liver diseases?*
No
Yes
7. Epilepsy? Seizures?*
No
Yes
8. Dizziness or fainting episodes?*
No
Yes
9. Treatment or medication for menstrual cramps?*
No
Yes
10. Disorders of the urinary or reproductive tract?*
No
Yes
11. Do you see a Medical/Physical specialist of any kind?*
No
Yes
12. Are you pregnant?*
No
Yes
13. Treatment or counseling with a mental health professional?*
No
Yes
14. Cardiac problems?*
No
Yes
15. Anorexia/Bulimia/Eating Disorder?*
No
Yes
16. Heatstroke/Heat Exhaustion?*
No
Yes
17. Physical or Sensory Limitation?*
No
Yes
18. Any other health complaint?*
No
Yes

If you chose "YES" on any of the questions, 1-18, please provide a brief description of your condition and any associated physical limitations:

Musculoskeletal Injuries
Do you currently have or have a history of: 


19. Knee, hip, ankle, shoulder, arm, back, or other injuries to muscles, tendons, ligaments, or bones sprains)? If so, please explain:

20. Have any of these injuries required surgery? If so, please explain:

Allergies/Medications 

21. Do you have any allergies? (including insect bites or bee stings)*
No
Yes

please list them, along with their severity and current treatment plan
22. Are you allergic to any medications?*
No
Yes
23. Are you currently taking any medications?*
No
Yes

Medication dosage/schedule
24. Have you ever been treated for any altitude related illness?*
No
Yes
25. Have you ever been treated for frostbite or other cold related injury/illness?*
No
Yes
26. Have your ever been treated for heat stroke or other heat related illness?*
No
Yes

Do you have any other physical, medical, or psychological conditions not listed above?
27. Do you exercise regularly?*
No
Yes

How often?

Restrictions

Duration/Distance

Intensity Level (easy/moderate/competitive)
28. Do you smoke?*
No
Yes

If so, how much?
29. Swimming ability*

Diet 


30. Do you have any dietary restrictions or food allergies? If yes, please describe (Are you vegetarian, vegan, gluten---free, or lactose intolerant? How strict are you? If you have a food allergy, what happens when you are exposed to the allergen?)

PLEASE READ CAREFULLY AND SIGN

The information provided above is a complete and accurate statement of any physical and psychological conditions, which may affect my participation in this trip. I realize that failure to disclose such information could result in serious harm to me, fellow participants, the guide. I agree to inform Colorado Adventure Guides should there be any change in my health status prior to the start of the trip. On the basis of the background information at the beginning of this form, and what I know or suspect about my physical and psychological health, I am fully capable of participating in this activity. I understand that if I have the potential for a severe allergic reaction to bee stings, insect bites, food, poison oak, or other substances that might be found in the outdoors, it is my responsibility to carry the proper medication with me. 


Emergency Contact Name/Relationship: *

Emergency Contact Phone Number: *
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Health History Form 

Colorado Adventure Guides' trips may be half-day, full-day, or multi-day wilderness expeditions in remote settings, where evacuation to modern hospital facilities is not immediately possible. You must expect extreme weather conditions ranging from snow storms to sleet to extreme heat. Sudden environmental changes are to be expected and anticipated. Depending on what activity you pursue with Colorado Adventure Guides you may be required to walk for several hours; carry a heavy load up uneven, steep terrain; sleep outdoors; experience long, tough days; and prepare meals and set up camp. If you have any questions about the activity and your participation, you may contact Colorado Adventure Guides directly.

Participant: Please circle YES or NO for each question. Each must be answered, but keep in mind that a "YES" answer does not necessarily mean you will not be able to participate. If you answer "YES" to any question, you may be asked to discuss your condition with the guide before departing. Guides reserve the right to make a decision on a participant's eligibility at any time. 

Do you currently have or have a history of: 

1. Respiratory problems? Asthma?*
No
Yes
2. Gastrointestinal disturbances?*
No
Yes
3. Diabetes or Hypoglycemia?*
No
Yes
4. Hypertension?*
No
Yes
5. Bleeding or blood disorders?*
No
Yes
6. Hepatitis or other liver diseases?*
No
Yes
7. Epilepsy? Seizures?*
No
Yes
8. Dizziness or fainting episodes?*
No
Yes
9. Treatment or medication for menstrual cramps?*
No
Yes
10. Disorders of the urinary or reproductive tract?*
No
Yes
11. Do you see a Medical/Physical specialist of any kind?*
No
Yes
12. Are you pregnant?*
No
Yes
13. Treatment or counseling with a mental health professional?*
No
Yes
14. Cardiac problems?*
No
Yes
15. Anorexia/Bulimia/Eating Disorder?*
No
Yes
16. Heatstroke/Heat Exhaustion?*
No
Yes
17. Physical or Sensory Limitation?*
No
Yes
18. Any other health complaint?*
No
Yes

If you chose "YES" on any of the questions, 1-18, please provide a brief description of your condition and any associated physical limitations:

Musculoskeletal Injuries
Do you currently have or have a history of: 


19. Knee, hip, ankle, shoulder, arm, back, or other injuries to muscles, tendons, ligaments, or bones sprains)? If so, please explain:

20. Have any of these injuries required surgery? If so, please explain:

Allergies/Medications 

21. Do you have any allergies? (including insect bites or bee stings)*
No
Yes

please list them, along with their severity and current treatment plan
22. Are you allergic to any medications?*
No
Yes
23. Are you currently taking any medications?*
No
Yes

Medication dosage/schedule
24. Have you ever been treated for any altitude related illness?*
No
Yes
25. Have you ever been treated for frostbite or other cold related injury/illness?*
No
Yes
26. Have your ever been treated for heat stroke or other heat related illness?*
No
Yes

Do you have any other physical, medical, or psychological conditions not listed above?
27. Do you exercise regularly?*
No
Yes

How often?

Restrictions

Duration/Distance

Intensity Level (easy/moderate/competitive)
28. Do you smoke?*
No
Yes

If so, how much?
29. Swimming ability*

Diet 


30. Do you have any dietary restrictions or food allergies? If yes, please describe (Are you vegetarian, vegan, gluten---free, or lactose intolerant? How strict are you? If you have a food allergy, what happens when you are exposed to the allergen?)

PLEASE READ CAREFULLY AND SIGN

The information provided above is a complete and accurate statement of any physical and psychological conditions, which may affect my participation in this trip. I realize that failure to disclose such information could result in serious harm to me, fellow participants, the guide. I agree to inform Colorado Adventure Guides should there be any change in my health status prior to the start of the trip. On the basis of the background information at the beginning of this form, and what I know or suspect about my physical and psychological health, I am fully capable of participating in this activity. I understand that if I have the potential for a severe allergic reaction to bee stings, insect bites, food, poison oak, or other substances that might be found in the outdoors, it is my responsibility to carry the proper medication with me. 


Emergency Contact Name/Relationship: *

Emergency Contact Phone Number: *
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Health History Form 

Colorado Adventure Guides' trips may be half-day, full-day, or multi-day wilderness expeditions in remote settings, where evacuation to modern hospital facilities is not immediately possible. You must expect extreme weather conditions ranging from snow storms to sleet to extreme heat. Sudden environmental changes are to be expected and anticipated. Depending on what activity you pursue with Colorado Adventure Guides you may be required to walk for several hours; carry a heavy load up uneven, steep terrain; sleep outdoors; experience long, tough days; and prepare meals and set up camp. If you have any questions about the activity and your participation, you may contact Colorado Adventure Guides directly.

Participant: Please circle YES or NO for each question. Each must be answered, but keep in mind that a "YES" answer does not necessarily mean you will not be able to participate. If you answer "YES" to any question, you may be asked to discuss your condition with the guide before departing. Guides reserve the right to make a decision on a participant's eligibility at any time. 

Do you currently have or have a history of: 

1. Respiratory problems? Asthma?*
No
Yes
2. Gastrointestinal disturbances?*
No
Yes
3. Diabetes or Hypoglycemia?*
No
Yes
4. Hypertension?*
No
Yes
5. Bleeding or blood disorders?*
No
Yes
6. Hepatitis or other liver diseases?*
No
Yes
7. Epilepsy? Seizures?*
No
Yes
8. Dizziness or fainting episodes?*
No
Yes
9. Treatment or medication for menstrual cramps?*
No
Yes
10. Disorders of the urinary or reproductive tract?*
No
Yes
11. Do you see a Medical/Physical specialist of any kind?*
No
Yes
12. Are you pregnant?*
No
Yes
13. Treatment or counseling with a mental health professional?*
No
Yes
14. Cardiac problems?*
No
Yes
15. Anorexia/Bulimia/Eating Disorder?*
No
Yes
16. Heatstroke/Heat Exhaustion?*
No
Yes
17. Physical or Sensory Limitation?*
No
Yes
18. Any other health complaint?*
No
Yes

If you chose "YES" on any of the questions, 1-18, please provide a brief description of your condition and any associated physical limitations:

Musculoskeletal Injuries
Do you currently have or have a history of: 


19. Knee, hip, ankle, shoulder, arm, back, or other injuries to muscles, tendons, ligaments, or bones sprains)? If so, please explain:

20. Have any of these injuries required surgery? If so, please explain:

Allergies/Medications 

21. Do you have any allergies? (including insect bites or bee stings)*
No
Yes

please list them, along with their severity and current treatment plan
22. Are you allergic to any medications?*
No
Yes
23. Are you currently taking any medications?*
No
Yes

Medication dosage/schedule
24. Have you ever been treated for any altitude related illness?*
No
Yes
25. Have you ever been treated for frostbite or other cold related injury/illness?*
No
Yes
26. Have your ever been treated for heat stroke or other heat related illness?*
No
Yes

Do you have any other physical, medical, or psychological conditions not listed above?
27. Do you exercise regularly?*
No
Yes

How often?

Restrictions

Duration/Distance

Intensity Level (easy/moderate/competitive)
28. Do you smoke?*
No
Yes

If so, how much?
29. Swimming ability*

Diet 


30. Do you have any dietary restrictions or food allergies? If yes, please describe (Are you vegetarian, vegan, gluten---free, or lactose intolerant? How strict are you? If you have a food allergy, what happens when you are exposed to the allergen?)

PLEASE READ CAREFULLY AND SIGN

The information provided above is a complete and accurate statement of any physical and psychological conditions, which may affect my participation in this trip. I realize that failure to disclose such information could result in serious harm to me, fellow participants, the guide. I agree to inform Colorado Adventure Guides should there be any change in my health status prior to the start of the trip. On the basis of the background information at the beginning of this form, and what I know or suspect about my physical and psychological health, I am fully capable of participating in this activity. I understand that if I have the potential for a severe allergic reaction to bee stings, insect bites, food, poison oak, or other substances that might be found in the outdoors, it is my responsibility to carry the proper medication with me. 


Emergency Contact Name/Relationship: *

Emergency Contact Phone Number: *
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Health History Form 

Colorado Adventure Guides' trips may be half-day, full-day, or multi-day wilderness expeditions in remote settings, where evacuation to modern hospital facilities is not immediately possible. You must expect extreme weather conditions ranging from snow storms to sleet to extreme heat. Sudden environmental changes are to be expected and anticipated. Depending on what activity you pursue with Colorado Adventure Guides you may be required to walk for several hours; carry a heavy load up uneven, steep terrain; sleep outdoors; experience long, tough days; and prepare meals and set up camp. If you have any questions about the activity and your participation, you may contact Colorado Adventure Guides directly.

Participant: Please circle YES or NO for each question. Each must be answered, but keep in mind that a "YES" answer does not necessarily mean you will not be able to participate. If you answer "YES" to any question, you may be asked to discuss your condition with the guide before departing. Guides reserve the right to make a decision on a participant's eligibility at any time. 

Do you currently have or have a history of: 

1. Respiratory problems? Asthma?*
No
Yes
2. Gastrointestinal disturbances?*
No
Yes
3. Diabetes or Hypoglycemia?*
No
Yes
4. Hypertension?*
No
Yes
5. Bleeding or blood disorders?*
No
Yes
6. Hepatitis or other liver diseases?*
No
Yes
7. Epilepsy? Seizures?*
No
Yes
8. Dizziness or fainting episodes?*
No
Yes
9. Treatment or medication for menstrual cramps?*
No
Yes
10. Disorders of the urinary or reproductive tract?*
No
Yes
11. Do you see a Medical/Physical specialist of any kind?*
No
Yes
12. Are you pregnant?*
No
Yes
13. Treatment or counseling with a mental health professional?*
No
Yes
14. Cardiac problems?*
No
Yes
15. Anorexia/Bulimia/Eating Disorder?*
No
Yes
16. Heatstroke/Heat Exhaustion?*
No
Yes
17. Physical or Sensory Limitation?*
No
Yes
18. Any other health complaint?*
No
Yes

If you chose "YES" on any of the questions, 1-18, please provide a brief description of your condition and any associated physical limitations:

Musculoskeletal Injuries
Do you currently have or have a history of: 


19. Knee, hip, ankle, shoulder, arm, back, or other injuries to muscles, tendons, ligaments, or bones sprains)? If so, please explain:

20. Have any of these injuries required surgery? If so, please explain:

Allergies/Medications 

21. Do you have any allergies? (including insect bites or bee stings)*
No
Yes

please list them, along with their severity and current treatment plan
22. Are you allergic to any medications?*
No
Yes
23. Are you currently taking any medications?*
No
Yes

Medication dosage/schedule
24. Have you ever been treated for any altitude related illness?*
No
Yes
25. Have you ever been treated for frostbite or other cold related injury/illness?*
No
Yes
26. Have your ever been treated for heat stroke or other heat related illness?*
No
Yes

Do you have any other physical, medical, or psychological conditions not listed above?
27. Do you exercise regularly?*
No
Yes

How often?

Restrictions

Duration/Distance

Intensity Level (easy/moderate/competitive)
28. Do you smoke?*
No
Yes

If so, how much?
29. Swimming ability*

Diet 


30. Do you have any dietary restrictions or food allergies? If yes, please describe (Are you vegetarian, vegan, gluten---free, or lactose intolerant? How strict are you? If you have a food allergy, what happens when you are exposed to the allergen?)

PLEASE READ CAREFULLY AND SIGN

The information provided above is a complete and accurate statement of any physical and psychological conditions, which may affect my participation in this trip. I realize that failure to disclose such information could result in serious harm to me, fellow participants, the guide. I agree to inform Colorado Adventure Guides should there be any change in my health status prior to the start of the trip. On the basis of the background information at the beginning of this form, and what I know or suspect about my physical and psychological health, I am fully capable of participating in this activity. I understand that if I have the potential for a severe allergic reaction to bee stings, insect bites, food, poison oak, or other substances that might be found in the outdoors, it is my responsibility to carry the proper medication with me. 


Emergency Contact Name/Relationship: *

Emergency Contact Phone Number: *
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*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releasees, and, for myself, my child and our heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child’s involvement or participation in these programs as provided above, even if arising from the negligence of the releasees, TO THE FULLEST EXTENT PERMITTED BY LAW.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Health History Form 

Colorado Adventure Guides' trips may be half-day, full-day, or multi-day wilderness expeditions in remote settings, where evacuation to modern hospital facilities is not immediately possible. You must expect extreme weather conditions ranging from snow storms to sleet to extreme heat. Sudden environmental changes are to be expected and anticipated. Depending on what activity you pursue with Colorado Adventure Guides you may be required to walk for several hours; carry a heavy load up uneven, steep terrain; sleep outdoors; experience long, tough days; and prepare meals and set up camp. If you have any questions about the activity and your participation, you may contact Colorado Adventure Guides directly.

Participant: Please circle YES or NO for each question. Each must be answered, but keep in mind that a "YES" answer does not necessarily mean you will not be able to participate. If you answer "YES" to any question, you may be asked to discuss your condition with the guide before departing. Guides reserve the right to make a decision on a participant's eligibility at any time. 

Do you currently have or have a history of: 

1. Respiratory problems? Asthma?*
No
Yes
2. Gastrointestinal disturbances?*
No
Yes
3. Diabetes or Hypoglycemia?*
No
Yes
4. Hypertension?*
No
Yes
5. Bleeding or blood disorders?*
No
Yes
6. Hepatitis or other liver diseases?*
No
Yes
7. Epilepsy? Seizures?*
No
Yes
8. Dizziness or fainting episodes?*
No
Yes
9. Treatment or medication for menstrual cramps?*
No
Yes
10. Disorders of the urinary or reproductive tract?*
No
Yes
11. Do you see a Medical/Physical specialist of any kind?*
No
Yes
12. Are you pregnant?*
No
Yes
13. Treatment or counseling with a mental health professional?*
No
Yes
14. Cardiac problems?*
No
Yes
15. Anorexia/Bulimia/Eating Disorder?*
No
Yes
16. Heatstroke/Heat Exhaustion?*
No
Yes
17. Physical or Sensory Limitation?*
No
Yes
18. Any other health complaint?*
No
Yes

If you chose "YES" on any of the questions, 1-18, please provide a brief description of your condition and any associated physical limitations:

Musculoskeletal Injuries
Do you currently have or have a history of: 


19. Knee, hip, ankle, shoulder, arm, back, or other injuries to muscles, tendons, ligaments, or bones sprains)? If so, please explain:

20. Have any of these injuries required surgery? If so, please explain:

Allergies/Medications 

21. Do you have any allergies? (including insect bites or bee stings)*
No
Yes

please list them, along with their severity and current treatment plan
22. Are you allergic to any medications?*
No
Yes
23. Are you currently taking any medications?*
No
Yes

Medication dosage/schedule
24. Have you ever been treated for any altitude related illness?*
No
Yes
25. Have you ever been treated for frostbite or other cold related injury/illness?*
No
Yes
26. Have your ever been treated for heat stroke or other heat related illness?*
No
Yes

Do you have any other physical, medical, or psychological conditions not listed above?
27. Do you exercise regularly?*
No
Yes

How often?

Restrictions

Duration/Distance

Intensity Level (easy/moderate/competitive)
28. Do you smoke?*
No
Yes

If so, how much?
29. Swimming ability*

Diet 


30. Do you have any dietary restrictions or food allergies? If yes, please describe (Are you vegetarian, vegan, gluten---free, or lactose intolerant? How strict are you? If you have a food allergy, what happens when you are exposed to the allergen?)

PLEASE READ CAREFULLY AND SIGN

The information provided above is a complete and accurate statement of any physical and psychological conditions, which may affect my participation in this trip. I realize that failure to disclose such information could result in serious harm to me, fellow participants, the guide. I agree to inform Colorado Adventure Guides should there be any change in my health status prior to the start of the trip. On the basis of the background information at the beginning of this form, and what I know or suspect about my physical and psychological health, I am fully capable of participating in this activity. I understand that if I have the potential for a severe allergic reaction to bee stings, insect bites, food, poison oak, or other substances that might be found in the outdoors, it is my responsibility to carry the proper medication with me. 


Emergency Contact Name/Relationship: *

Emergency Contact Phone Number: *
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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