2016 Basic Mountaineering Course Student Registration
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PERSONAL INFORMATION
First Name *
Last Name *
Address *
City *
State *
Zip *
Home Phone (please enter with dashes: e.g. 360-555-5555) *
Cell Phone (please enter with dashes: e.g. 360-555-5555) *
email *
Date of Birth *
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DD
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YYYY
Gender
EMERGENCY CONTACT INFORMATION
Please provide information for a person to contact in case of an emergency during classroom sessions and weekend outing sessions
Name of person to contact in case of emergency *
Relationship to you
Phone # of emergency contact (please enter with dashes: e.g. 360-555-5555) *
MEDICAL INFORMATION
Describe your current physical fitness and level of activity
Do you have any medical conditions? *
If yes, explain the medical condition(s)
Do you have any allergies? *
If yes, explain the allergies
Are you taking any medications? *
If yes, describe the medications
PERSONAL MEDICAL INSURANCE IS REQUIRED TO TAKE THIS COURSE.
Do you currently have medical Insurance? *
Insurance Provider
Name of policy holder
Relation of policy holder to you
SIGNATURE
By entering my initials below, I certify that the above information is accurate and true to the best of my knowledge. *
Today's date *
MM
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DD
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YYYY
Submit
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