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Owners/Operators
Contact Us
Home
Services
Rock Climbing - Beginner
Rock Climbing - Advanced
Ice & Mixed Climbing
Events
Gear Rental
Store
Owners/Operators
Contact Us
Health History and Emergency contact information
safety is high priority in all programs. we strongly recommend that you consult your health care provider if you are pregnant or have any medical or emotional conditions that may affect your ability to participate safely.
certain health information may be important for out guides to know during your climbing program with twin cities rock and ice llc. all information on the following forms will be kept confidential and it will be seen only by staff, medical personnel, or other who know and understand its confidential nature.
Participant
Name
*
Name
First Name
Last Name
Today's Date
Today's Date
MM
DD
YYYY
Age
*
Date of Birth
*
Date of Birth
MM
DD
YYYY
Sex
Male
Female
Height
Weight
Emergency contact
In case of emergency, please contact
Name
Name
First Name
Last Name
Relationship
Primary Phone
*
Primary Phone
(###)
###
####
Secondary Phone
Secondary Phone
(###)
###
####
Health History
do you currently have or have you had a history of:
Hypertension
Yes
No
Heart attach or heart disease
Yes
No
Heart palpitations or murmur
Yes
No
Chest pain / pressure
Yes
No
Stroke
Yes
No
Smoking
Yes
No
Diabetes
Yes
No
Respiratory problems
Yes
No
Gastrointestinal concerns
Yes
No
Genitourinary concerns
Yes
No
Bleeding or blood disorders
Yes
No
Infectious diseases
Yes
No
Neurologic problems, seizures
Yes
No
Dizziness or fainting
Yes
No
Mental Health concerns
No
Yes
Recent illness
Yes
No
Joint or extremity pain / injury
Yes
No
Spine pain or injury
Yes
No
Dietary restrictions
Yes
No
Eating disorders
Yes
No
Frostbite or cold injury
Yes
No
Heat injury
Yes
No
Altitude illness
Yes
No
Major surgery
Yes
No
Physical disability
Yes
No
Allergies (insects, food, drugs, etc.)
Yes
No
Are you currently under the care of a medical professional?
Yes
No
Are you pregnant?
Yes
No
Any other health concerns?
Yes
No
Do you wear contacts?
Yes
No
Are you currently using or carrying any medication?
Yes
No
If you answered "yes" to any of the above question, please describe below.
Declaration and Consent
To the best of my knowledge, the above information is a complete and accurate representation of my pertinent medical history. I declare that I am in good physical health and believe that I am able without reservation or limiting conditions to physically withstand and cope with the indicated rigors of this program. In the event of an emergency, permission is given for any evacuation, medical intervention and care that may become necessary for my immediate well being.
Electronic Signature Consent
*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.
Electronic Signature
*
Electronic Signature
First Name
Last Name
Date
*
Date
MM
DD
YYYY
Thank you!
