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Petra Cliffs Mountaineering School Health History Form

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 situation. Programs may take place in remote locations where advanced medical care is not quickly available. For our guides to conduct these programs it is essential that we are fully aware of any health issues regarding our participants. The information you provide may assist us in the unlikely event of an accident. Your responses will be kept in the strictest of confidence. Please call Petra Cliffs Climbing Center at 802-657-3872 with any questions. Thank you.

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
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*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Participant Information

Participant Pronouns

Participant Height

Participant Weight
Are you taking any medications for any medical issues?*
No
Yes

If Yes, which medications, and for what? What are the side effects?
Do you have any Allergies or Anaphylaxis?*
No
Yes

If Yes, to what, and how severe? In case of anaphylaxis, do you carry an Epi Pen?
Do you have any Musculoskeletal injuries?*
No
Yes

If Yes, please list any relevant past or present musculoskeletal injuries.
Any history of Heart Conditions?*
No
Yes

If Yes, please list any heart conditions and effects.
Do you have Seizures?*
No
Yes

If Yes, is there anything we should be aware of with seizures?
Do you have Diabetes?*
No
Yes

If Yes, is there anything we should be aware of with diabetes?
Do you have Asthma?*
No
Yes

If Yes, do you carry an inhaler? What else should we know?

Please advise us if there is anything else we should be aware of:
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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
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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