This health statement is confidential. It is designed to give the trip leaders a better picture of who you are so that we can better prepare for and serve your individual needs. In the event of an injury this statement will be the most important information we have about your medical history, so please be as thorough as possible. THANKS!
General Information
Full Name *
If you have a preferred name, please place in parenthesis after your birth name. Example: Johnathan Doe (John Doe)
Your answer
CID # *
Write "N/A" if not applicable.
Your answer
Local Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Height *
Example: 5' 11" or 180.34 cm
Your answer
Weight *
Example: 175 lbs or 79.38 Kilograms
Your answer
Birthdate *
MM
/
DD
/
YYYY
Age *
Your answer
Cell Phone Number *
No special characters please - just numbers only.
Your answer
Email Address *
Your answer
Activity Level
Do you smoke? *
Do you wear corrective lenses? *
Can you swim? *
Your general activity level is... *
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