Retreat Registration – Northern Rockies Fitness

First Name *

Last Name

Phone

Email Address *

Date Of Birth

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Total Amount To Be Paid

Do you want to pay in installments? *YesNo

Emergency Contact Name

Emergency Contact Phone Number

Do 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?

YesNo

Do 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?

YesNo

Do 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?

YesNo

Is there anything else we should know about your health or ability to participate in the trip?

YesNo

If 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?

Date

Signed Date