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Please complete for each member of your group
*
Indicates required field
Name
*
First
Last
Email
*
Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Are you responsible for your group?
*
Yes
No
Not Sure
Number of participants in your group
*
1
2
3
4
5
6
7
8
9
10+
Number of participants in your group, including yourself.
Emergency Contact Person:
*
First
Last
Emergency Contact Phone Number
*
Your Doctor / Hospital
*
First
Last
Doctor's Phone Number
*
Medical Insurance Provider
*
Insurance ID Number
*
Your Age
*
Height
*
Weight
*
Shoe Size
*
For Microspikes or Snowshoes
Do you have any ALLERGIES?
*
YES
NO
NOT SURE
If yes, allergic to what? (Foods, Medications, Bees, etc. – Please be specific)
*
Do you carry an Epi-Pen?
*
YES
NO
If yes, what is the Epi-Pen for? Please remember to bring your Epi-Pen with you, and an extra if you have it.
*
Do you carry an asthma inhaler?
*
YES
NO
If yes, for what type of asthma, and when was your last attack?
*
Do you take or carry any other medications?
*
YES
NO
If yes, what other med(s) and for what?
*
Desired activity level:
*
Very Relaxed
Relaxed
Moderate
Vigorous
Extreme
What is your fitness level?
*
Not very fit
Somewhat fit
Moderately fit
Very fit
Please describe any past heat or cold injuries:
*
Please describe any dietary restrictions:
*
Please describe any exercise-induced illnesses or loss of consciousness:
*
Comments, requests or special needs:
*
May we share photos of you during your activity on social media, our website, advertising, and/or in our literature?
*
YES, I want to be famous!
NO, please do not share any photos of me
I understand the risks associated with this activity, and that I will have to sign a release of liability waiver before participating.
*
I Agree
Submit
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Hiking & Trip Info
