Participant's Name*

Phone Number*

Address Line 1*

Address Line 2

City*

State*

Zip Code*

Email Address*

Date of Birth*

Occupation

Who to contact in an emergency*

Relationship to you

Emergency contact phone number*

Do you have Diabetes?*
NoYes

How well is it under control?

Do you have a history of Seizures?*
NoYes

How well is it under control?

Do you have Heart Disease?*
NoYes

Do you have a history of or currently have ashtma?*
NoYes

If you use an inhaler, do you have it with you?
NoYes

Do you have a history of anaphylaxis or allergies?*
NoYes

If so, do you have an EpiPen or other medications with you?
YesNo

Do you have relevant musculoskeletal injuries or related surgeries?*
NoYes

If so please explain...

Do you have problems with vision or hearing?*
NoYes

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?*
NoYes

If so please explain...

Do you have international medical insurance?*
NoYes

If so, who is your carrier?

Are you under the influence of illegal drugs or alcohol?*
NoYes

Do you have any previous climbing experience?*
NoYes

If so, please explain...

If there is a photo you would like us to use for your campaign page, please upload it now.

Type your name.*

Date*

By checking this box I am agreeing that all information on this form is accurate.

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