Retreat Registration First Name *Last NamePhoneEmail Address *Date Of BirthStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeCountry AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabweWhich retreat(s) are you registering for? *Boulder Gardens/Babcock Falls, Dec. 17, 2022Teepee Falls/Quality Falls, Jan. 8, 2023Babcock Seeps, Feb. 5, 2023Sikanni River Snowshoe, Feb. 10-13, 2023Bullmoose/Flatbed Falls, Feb. 25, 2023Perry/Flatbed Falls, Mar. 11, 2023Beattie Lake Backpacking - July 6-10, 2023Wild Women Take The North, July 16-24, 2023Bootski Lake, July 28-30, 2023Windfall Lake, Aug. 4-6, 2023Muskwa River Adventures, Aug. 13-20, 2023Heart of the MacDonald, Aug. 25-28, 2023Wild Women Take The North, July 21-29, 2024Total Amount To Be PaidDo you want to pay in installments? *YesNoEmergency Contact NameEmergency Contact Phone NumberDo you have, or have you ever been told by a doctor that you had: epilepsy, high blood pressure, heart or lung disease, heart murmur or pacemaker, asthma, colitis or intestinal trouble, ulcers or stomach trouble, diabetes, any significant back, foot, hip, or leg problems, or any other disease or condition?YesNoDo you have, or have you had, any significant illness requiring the regular care of a doctor? Do you take medications regularly? Which ones and for what condition?YesNoDo you have any allergies or allergic reactions to drugs? Which ones, and what is the effect? Have you been hospitalized in the last five years?YesNoIs there anything else we should know about your health or ability to participate in the trip?YesNoIf answered yes to any questions, please explain as best as you can. Safety and wellbeing are a priority for Northern Rockies Fitness, and in order to ensure this we need an accurate understanding of your present health. Please take the time to fill this form out accurately. We keep any information on this form confidential, and would only ever share the information in a medical emergency, to emergency response personnel. The completion of this form is mandatory for participation on our adventures. We require the form filled out at the time of booking, or as soon after as possible. We reserve the right to deny participation on our adventures, based on our assessment of your health, if we feel we cannot ensure your safety on one of our adventure tours. Many of our adventure tours take place in remote wilderness areas, where medical facilities are far away. By disclosing your information on this Medical Form, you understand the risks associated in participating on our tours. Failure to disclose information can lead to complications in the event of an emergency. Please be honest about everything, this information is to protect you.How did you hear about us?DateSigned DateRegister