Registration and Medical Form
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Email *
First Name *
Last Name *
Please describe your climbing experience as it relates to your trip/clinic. *
What are your goals? What are your concerns?
 *
How did your hear about us/this clinic? *
Address *
City *
State *
Zip Code *
Country *
Cell Phone Number *
Emergency Contact Name *
Emergency Contact Phone *
Date of Birth *
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/
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Gender *
Height *
Weight *
Physical Condition *
Have you been ill or hospitalized in the last 6 months? *
If yes, please explain.
Do you take any medications regularly? *
If yes, please describe.
Do you have any of the following medical conditions?  (Check all that apply - If you check any boxes other than 'None', please answer the following 4 questions.) *
Required
How long have you had the above condition?
Is the condition under control?
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Do you take any medications related to the conditions and if so, what are they?
If you have allergies, what are you allergic to?
Do you have any problems with your hearing or vision? *
If yes, please describe.
Do you have any muscular or skeletal deficiencies or recent surgeries that might hinder your mobility and ability to participate in your guided trip? *
If yes, please describe.
Is there any other medical or physical concern that might impact your ability to fully enjoy your guided experience? *
If yes, please explain.
Thank you! We look forward to climbing together.
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