Participant Name
*
First Name
Last Name
Pronouns
He/Him/His
She/Her/Hers
They/Them/Theirs
Other
Preferred Name (if any)
Email
*
Phone
*
(###)
###
####
Phone (if non-US)
Country
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Briefly describe participant's relevant climbing or skiing experience, if any.
*
Emergency Contact Name
*
Emergency Contact Phone
*
(###)
###
####
Emergency Contact Relationship
*
Spouse or Partner
Friend
Parent or Grandparent
Sibling
Other
Date of Birth (of participant)
*
List any/all medications and dosages you will be taking while on the trip and why:
*
We realize that your medical history is personal and sensitive, and we promise to exercise absolute discretion with any information provided. Due to the strenuous and often remote nature of many of our programs, it is of the utmost importance that you answer the following questions honestly and completely. No medical conditions will automatically disqualify you from participation in any Now!Climbing programs, but failure to fully disclose any relevant medical conditions may impede our ability to properly manage your safety while in the field. We thank you in advance for your cooperation in allowing us to maintain the highest standards in managing your well-being.
List any/all major accidents, illnesses, or operations you've incurred in the past 5 years:
*
List any/all physical limitations or medical conditions that may affect your ability to participate in your intended program:
*
List any/all allergies to food and/or medication:
*
For overnight trips, list any/all dietary needs or concerns you may have, i.e vegetarianism, gluten-free diets, foods you don't eat, etc:
