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MITOC WS 2012 Personal Info Form
Everyone must fill this out! This information will be shared with your WS leaders for logistical, safety, and further trip planning purposes only. Leaders reserve the right to waitlist you from a trip because you did not fill out this form.
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* Indicates required question
First and last name:
*
Your answer
Email:
*
Your answer
Cell phone number
*
(xxx) xxx-xxxx
Your answer
Home phone number
*
(xxx) xxx-xxxx
Same as cell phone
Other:
Allergies:
*
Ex. bee stings, peanuts
None
Other:
Medication:
*
None
Other:
Medical history:
*
Anything your trip leader would want to know about. Ex. severe bee allergies, stroke at age 18, torn ACL+surgery a year ago
None
Other:
Dietary restrictions
*
Your answer
Emergency contact name:
*
Your answer
Emergency contact email:
*
Your answer
Emergency contact phone number:
*
(xxx) xxx-xxxx
Your answer
Emergency contact relation:
*
Mother, brother, room mate, best friend
Your answer
Are you a leader or participant?
*
Participant
Leader
Any medical or wilderness training / qualification / background?
*
Please give details of any medical, technical, or leadership training and qualifications relevant to the winter environment, or enter "none"
Your answer
How many years have you been to WS?
*
0
1
2
3
4
5
Winter Experience:
*
In 1-3 sentences: previous winter outdoors experience. Include the type of trip (x-country ski, above treeline, snow-shoe, ice climbing, etc), or enter "none"
Your answer
Personal objectives of WS
*
Your answer
How are your top rope belaying and figure 8 knot tying skills?
Only applicable if you would like to go ice climbing
Tons of experience lead belaying and catching leader falls
Tons of experience top rope belaying
Done it a few times before
Done it before but I need a refresher
Never belayed before
I don't know what any of this means!
Clear selection
Are you a keyholder to the MITOC cabins?
*
Camelot and Intervale
Camelot
Intervale
Neither
DRIVER QUESTIONS: If you answer no to this question, skip to bottom and press submit. Do you have a car?
*
Yes
No
Car make:
ex. Ford, Toyota, Fiat, Ferrari
Your answer
Car model:
ex. Taurus, Prius, Fancydancy3000
Your answer
Car year:
Your answer
Color:
Your answer
Description:
ex. 4-door sedan, station wagon, hippie van
Your answer
Distinguishing features:
ex. missing back bumper, stickers, ski rack, looks nearly totaled
Your answer
License plate state:
Your answer
License plate number:
Your answer
Max passengers: (not including driver)
1
2
3
4
5
6
7
8
9
10
Clear selection
Max passengers with winter gear: (not including driver)
1
2
3
4
5
6
7
8
9
10
Clear selection
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