In regard to the specific trip you are participating in, please give a detailed account of your experience and level. Be specific to the individual sports, i.e.: rock and ice climbing, alpine ascents, and skiing.
Please elaborate on any questions you have regarding equipment.
Please list your provider and policy number
Please list your provider and policy number.
If you marked any of the above, please explain below. Include dates, severity, treatment, current symptoms and limitations:
List any/all medications that you take regularly or intermittently and why:
List any/all physical limitations or medical conditions that may restrict your ability to participate in this program.
List any/all allergies to food and/or medication:
