2020 Basic Mountaineering Course Student Registration

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Email *

Minimum Course Requirements:

--Must be 18 years or older
--Must be in good physical condition
--Must attend all the classes and outings

PERSONAL INFORMATION

First Name *

Last Name *

Address *

City *

State/Province *

Zip *

Home Phone (please enter with dashes: e.g. 360-555-5555) *

Cell Phone (please enter with dashes: e.g. 360-555-5555) *

email *

Date of Birth *

YYYY

Gender

EMERGENCY CONTACT INFORMATION

Please provide information for a person to contact in case of an emergency during classroom sessions and weekend outing sessions

Name of person to contact in case of emergency *

Relationship to you

Phone # of emergency contact (please enter with dashes: e.g. 360-555-5555) *

MEDICAL INFORMATION

Describe your current physical fitness and level of activity

Do you have any medical conditions? *

If yes, explain the medical condition(s)

Do you have any allergies? *

If yes, explain the allergies

Are you taking any medications? *

If yes, describe the medications

PERSONAL MEDICAL INSURANCE IS REQUIRED TO TAKE THIS COURSE.

Do you currently have medical Insurance? *

Insurance Provider *

Name of policy holder *

Relation of policy holder to you *

SIGNATURE

By entering my initials below, I certify that the above information is accurate and true to the best of my knowledge. *

Today's date *

YYYY

A copy of your responses will be emailed to the address you provided.

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