| Personal Information |
| First Name |
|
Last Name |
|
| Phone |
|
Email |
|
| Address |
|
City |
|
| State |
|
Zip |
|
| Status |
|
Class of |
|
| Trip Selection |
| Please select the trip(s) for which you'd like
to register or item to purchase. Note: registration of multiple trips is for one person, to register multiple people, please register them seperately. |
|
| *If you are ordering a Gift Certificate, please enter in the inforamtion for whom the gift certificate is to be issued. |
| Release of Liability |
| Please acknowledge that you have read and agree to the
following: |
|
Release of Liability
and Experiential Learning and Adventure Center Policies
|
| Health Statement and Permission to Treat: |
| Birth Date: |
|
Gender: |
|
| Height: |
|
Weight: |
|
| Health Insurance Company: |
|
Policy Number: |
|
| Emergency Contact #1: |
|
| Relationship: |
|
Phone |
|
| Emergency Contact #2 |
|
| Relationship |
|
Phone: |
|
| Medical History |
| This information is for your own medical
history. If registering more than one person, you will be contacted
to submit medical information for others. |
| Please let us know if you have any special dietary needs
(i.e., vegetarian, lactose intolerant, no red meat) |
|
| 1. Please list any previous/recent or existing/chronic medical conditions (e.g. physical and/or mental disabilities, injuries or illnesses) that could limit your participation in any way. How do these affect your daily life? |
|
| 2. Please list any previous or existing allergies (e.g. trees, pollens, molds, foods, insect stings, medications, etc.). Have you been hospitalized because of an attack? Do you have medication to control the reaction? If so, what kind? |
|
|
| 3.Do you suffer from asthma? If so, what triggers it (e.g. exercise, temperature, pollens, etc.)? Are you taking medications to control it? If so, what kind? |
|
| 4. Please list any medications you are currently taking (e.g. over-the-counter, prescription, birth control, etc.). Are you experiencing any problems as a result of this medication? Are there side-effects we should be aware of (e.g. increased susceptibility to heat and/or light, etc.)? |
|
| Health Waiver |
| Please acknowledge that you have read and agree to the
following: |
| Health Waiver |
Payment Information |
|
Payment instructions will follow on next
screen.
Please press Submit only once. |
