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Client Questionnaire & Covid Screening

Please fill in as completely as possible. This information should not prevent you from participating and allows us to be prepared while traveling in wilderness settings.

Fitness and Medical disclosure

 

Today's Date: November 29, 2021 

Please select who will be participating...
AdultMinor
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First Participant's Name

First Name*

Last Name*

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

Age *

Height *

Weight *

Covid Screening 

Have you experienced any of the following symptoms in the past 48 hours? *
fever or chills
cough
shortness of breath or difficulty breathing
fatigue
muscle or body aches
headache
new loss of taste or smell
sore throat
congestion or runny nose
nausea or vomiting
diarrhea
none of the above
Within the past 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with *
Anyone who is known to have laboratory-confirmed COVID-19.
Anyone who has any symptoms consistent with COVID-19.
No
Unknown
Are you isolating or quarantining because you may have been exposed to a person with COVI 19 or are worried that you may be sick with COVID-19?*
Are you currently waiting on the results of a COVID-19 test?*

Medical History 

Pre existing medical conditions and orthopedic injuries. *
asthma
allergies
diabetes
heart conditions
epilepsy
none
Other

If Other, please explain

Describe pertinent medical and orthopedic history.

Medications

Fitness & Experience 


What is your daily, weekly, monthly fitness routines? What is your pretrip preperation *

List any previous skiing, snowboarding, mountaineering, or rock climbing experience. Any other outdoor adventure experience that could be relevant. *
First Participant's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

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

Age *

Height *

Weight *

Covid Screening 

Have you experienced any of the following symptoms in the past 48 hours? *
fever or chills
cough
shortness of breath or difficulty breathing
fatigue
muscle or body aches
headache
new loss of taste or smell
sore throat
congestion or runny nose
nausea or vomiting
diarrhea
none of the above
Within the past 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with *
Anyone who is known to have laboratory-confirmed COVID-19.
Anyone who has any symptoms consistent with COVID-19.
No
Unknown
Are you isolating or quarantining because you may have been exposed to a person with COVI 19 or are worried that you may be sick with COVID-19?*
Are you currently waiting on the results of a COVID-19 test?*

Medical History 

Pre existing medical conditions and orthopedic injuries. *
asthma
allergies
diabetes
heart conditions
epilepsy
none
Other

If Other, please explain

Describe pertinent medical and orthopedic history.

Medications

Fitness & Experience 


What is your daily, weekly, monthly fitness routines? What is your pretrip preperation *

List any previous skiing, snowboarding, mountaineering, or rock climbing experience. Any other outdoor adventure experience that could be relevant. *
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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