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Date of Birth*
Who to contact in an emergency*
Relationship to you
Emergency contact phone number*
Do you have Diabetes?*
How well is it under control?
Do you have a history of Seizures?*
Do you have Heart Disease?*
Do you have a history of or currently have ashtma?*
If you use an inhaler, do you have it with you?
Do you have a history of anaphylaxis or allergies?*
If so, do you have an EpiPen or other medications with you?
Do you have relevant musculoskeletal injuries or related surgeries?*
If so please explain...
Do you have problems with vision or hearing?*
To the best of your knowledge, do you have any other medical or health issues that would prevent you from fully participating in activities regarding this charitable climb?*
Do you have international medical insurance?*
If so, who is your carrier?
Are you under the influence of illegal drugs or alcohol?*
Do you have any previous climbing experience?*
If so, please explain...
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Type your name.*
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