Trip Registration

Personal Information
First Name		Last Name
Phone		Email
Address		City
State		Zip
Status		Class of
Please let us know if you have any special dietary needs (i.e., vegetarian, lactose intolerant, no red meat)

Outdoor Programs
Please select the trip for which you'd like to register.

Release of Liability
Please acknowledge that you have read and agree to the following:
Release of Liability
Health Statement and Permission to Treat:
Birth Date:		Sex:
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.
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
Credit Card

Payment instructions will follow on next screen. Please press Submit only once.

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