You can print this form from the Web and submit it.
NAME___________________________________________ SEX________
AGE________ CLASS/AFFILIATION __________
HOME ADDRESS_________________________________________ HOME PHONE ____________
_____________________________________________________ WORK PHONE _____________
CITY______________________________________ STATE_________ ZIP __________
HEIGHT: __________ inches WEIGHT:__________ pounds IN-SEAM: __________ inches SHOE SIZE: __________
T-SHIRT SIZE (100% cotton): _____S _____M _____L _____XL _____XXL
CURRENT EXERCISE ACTIVITY: List any physical activities you engage in, their frequency, duration and level of intensity.
| Activity | Frequency | Approximate Time/Distance | Leisurely | Moderately | Intensely |
CURRENT PHYSICAL CONDITION: Please check the highest activity level in each category that you feel you can comfortably attain.
| Walking (average 3 mph) | __1 mile in 35 minutes | __1 mile in 30 minutes | __1 mile in 25 minutes or less | __Unsure |
| Jogging (average 5 mph) | __1 mile in 12 minutes | __3 miles in 36 minutes | __5 miles in 60 minutes | __Unsure |
| Cycling (average 10 mph) | __5 miles in 30 minutes | __10 miles in 60 minutes | __20 miles in 120 minutes | __Unsure |
| SWIMMING ABILITY: ____Non-swimmer ____Poor
____Fair ____Good ____Very Good Note: Non-swimmers will not be allowed to participate in water activities such as rafting or kayaking. |
CURRENT HEALTH STATUS: Please indicate if you have any physical disabilities or conditions that would interfere with or limit your participation in the trip. If you are unsure, explain the trip to your physician and ask for his/her advice. (None of these will necessarily prohibit your participation, but for your own safety, we must be aware of such conditions.) If you answer yes to any of the questions below, please specify in detail below, indicating the item number. There are certain medical conditions that would preclude your participating in the hike or other activities.
| 1. Previous Altitude-related illness | __Yes __ No | 11. Vertigo (balance problems) | __ Yes __ No |
| 2. Respiratory problems | __ Yes __ No | 12. High or low blood sugar | __ Yes __ No |
| 3. Asthma | __ Yes __ No | 13. Seizure disorders | __ Yes __ No |
| 4. Back problems | __ Yes __ No | 14. Current pregnancy | __ Yes __ No |
| 5. Anemia, sickle cell disease or bleeding disorder | __ Yes __ No | 15. History of brain tumor, aneurysm or AV malformation | __ Yes __ No |
| 6. Joint problems (e.g. knees, ankles, or hips) | __ Yes __ No | 16. Heart disease | __ Yes __ No |
| 7. High or low blood pressure | __ Yes __ No | 17. Any recent illness | __ Yes __ No |
| 8. Recent sinus or ear infections | __ Yes __ No | 18. Recent surgery (last 6 months) | __ Yes __ No |
| 9. Problems with hearing or vision | __ Yes __ No | 19. Recent hospitalization | __ Yes __ No |
| 10. Reactions to temperature extremes | __ Yes __ No | 20. Other | __ Yes __ No |
| Item # | Detailed description (include restrictions, if any) |
ALLERGIES: Please indicate any allergies you have, your allergic reactions, and any medication required.
| Allergy | Reaction | Medication Required (if any) |
| Insect stings (bees, wasps, etc.) ___Yes ___ No |
||
DIETARY RESTRICTIONS OR FOOD ALLERGIES: (If vegetarian or Kosher, please specify dietary restrictions.)
MEDICATIONS: Please indicate any medications you are currently taking (other than allergy medications), for what condition, and whether you will need to take it during the trip. If you need to take medication during the trip, be sure you have an ample supply.
| Medication | Condition | Do you need this during the trip? |
| . | . | ___Yes ___ No |
| . | . | ___Yes ___ No |
REQUIRED IMMUNIZATIONS: The following immunizations are required for your participation.
| Immunization | Required Interval | Date of Last Immunization |
| Tetanus | Within 10 years. Recommended within 5 years. |
_____Please send me information on a religious exemption.
MEDICAL INSURANCE (Required): list group providing coverage & policy number
| Insurance Provider | Policy Number |
Describe any previous outdoor experience including mountain biking, rock climbing or kayaking.
_________________________________________________________________________________________
_________________________________________________________________________________________
I hereby certify that the answers set forth above are true. I hereby certify that I am aware that specific personal equipment as provided in the furnished Equipment List is necessary for my participation in this program and that it is my obligation to provide this equipment. I acknowledge that my failure to provide the necessary equipment may prevent my full participation in this trip. I understand that I will not be entitled to a refund of some or all of my payment.
I acknowledge that while Outdoor Action and Princeton University are making every effort to ensure the successful operation of this trip, that Outdoor Action and Princeton University are not responsible for my travel arrangements to and from Colorado. I also understand that a number of the optional activities of this program are operated by third-party outfitters and that Outdoor Action and Princeton University are neither in control of nor responsible for the operation of any third-party, outside companies engaged for this program.
I acknowledge that my participation in this trip is voluntary. I am aware that my participation in this trip involves activities both at high altitude and in remote locations with limited access to hospital medical care. I am aware of the potential hazards of this activity, including, but not limited to, high altitude illnesses, gastro-intestinal infections from drinking untreated water, heat or cold related illnesses, falls, inclement weather, lightning, and difficult trail conditions. There are risks of travel as well, including risks associated with motor vehicles and poor driving conditions.
I believe that I have been fully and adequately briefed regarding the risks inherent in the trip. I have weighed the dangers inherent in this trip, the risks presented to my own health and well being, and my personal desire to participate in this trip. I have concluded that the risks are acceptable and are outweighed by my desire to participate.
In consideration of Princeton University enabling me to participate in this Outdoor Action program, I voluntarily assume all risks associated therewith. I hereby release the Trustees of Princeton University, its officers, agents, employees, and students, from any and all claims that I may have as a result of personal injury (including death), or property damage arising out of or connected in any way with this program, unless those claims arise as a direct result of the gross negligence or willful misconduct of Princeton University. This release includes claims arising out of the rendering of emergency medical procedures or treatment, if any. I hereby give my consent for medical treatment should it be required during this trip. This waiver is binding on my heirs and assigns.
In witness whereof, I have caused this release to be executed this __________ day of ____________________, 1997.
SIGNATURE: ________________________________________________________________
Copyright © 1997, all rights reserved, OutdoorAction Program and 250th Office, Princeton University.