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 our 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

YYYY

Age *

Date of Birth *

Date of Birth

YYYY

Gender

Male

Female

Other / Prefer not to say

Height

Weight

Emergency Contact

In case of emergency, please contact

Name *

Name

First Name

Last Name

Relationship

Primary Phone *

Primary Phone

(###)

###

####

Secondary Phone

(###)

###

####

Medical Insurance

Will you have medical insurance coverage at the time of the outing?

Yes

Health History

Do you currently have or have you had a history of:

Hypertension

Yes

Heart attack or heart disease

Yes

Heart palpitations or murmur

Yes

Chest pain / pressure

Yes

Stroke

Yes

Smoking

Yes

Diabetes

Yes

Respiratory concerns

Yes

Gastrointestinal concerns

Yes

Genitourinary concerns

Yes

Bleeding or blood disorders

Yes

Infectious diseases

Yes

Neurologic problems, seizures

Yes

Dizziness or fainting

Yes

Mental health concerns

Yes

Recent illness

Yes

Joint or extremity pain / injury

Yes

Spine pain or injury

Yes

Dietary restrictions

Yes

Eating disorders

Yes

Frostbite or cold injury

Yes

Heat injury

Yes

Altitude illness

Yes

Major surgery

Yes

Physical disability

Yes

Allergies (insects, food, drugs, etc.)

Yes

Are you currently under the care of a medical professional?

Yes

Are you pregnant?

Yes

Any other health concerns?

Yes

Do you wear contacts?

Yes

Are you currently using or carrying any medication?

Yes

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

YYYY

Thank you! We’ll send you invoice for the climbing program selected shortly!