Obsidians/EMR Basic Climb School 2017: Questionnaire
Please complete this form in its entirety. You will also have to fill out a Liability Release at the first class meeting.

Your registration is not complete and your spot in the class is not confirmed until you have paid!

Name
Your answer
Mobile Phone Number
Your answer
Email address
Your answer
Age
Are you a member of the Obsidians?
Are you a member of Eugene Mountain Rescue?
I will pay
Please briefly describe any previous climbing experience:
Your answer
The following is equipment needed for this course. Any gear that you do not have will be loaned to you during the course at no additional charge. Please mark equipment that you have.
Climb school rock sessions are either Saturday, April 15th or Sunday, April 16th. Please choose which best describes your availability.
Any other comments?
Your answer
Obsidians/EMR Basic Climb School 2016: Emergency Contact Information
Please fill out the following health and emergency information. This information will be kept confidential and referred to only in the case of an emergency.
Emergency Contact Name
Your answer
Emergency Contact Phone Number
Your answer
Physician Name
Your answer
Physician Address
Your answer
Physician Phone Number
Your answer
Health Information
Health and Accident Insurance is your responsibility. We recommend that you obtain appropriate insurance.
Describe any illness or injury which might affect your ability to participate fully and safely in this course, including but not limited to: back or knee problems, cardiac or respiratory ailments, diabetes, allergies, migraines, sensitivity to cold, or seizure disorders.
Your answer
List any drugs or medications you are currently taking that may affect your ability to participate or are related to management of the conditions described above:
Your answer
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