Emergency Contact and Medical Information

Select Event Title *

Event Organizer

Date

Event Type

Have you traveled to an area with more than 200 Corona Virus case, or do you have flu/cold like symptoms such as cough, fever, shortness of breath, sneezing, headache or muscle pain?

Yes

No

Paragraph

Will you be fasting on the day of the event? *

Yes

No

Will you bring at least 1.5 Liters of water for this hike? *

Yes

No

Note:

Do you have a history of heart, high-blood pressure, are pregnant, or any other medical condition that may be adversely affected by exercise? *

Yes

No

Note:

Upload Doctor's Note Here: *

Maximum upload size: 67.11MB

Personal Information (Only Accessible to the Event Organizer for this event)

Participant's Real First Name and Last Name *

Participant is at least 18 years old *

Yes

No

Participant's Email *

Parent/Gaurdian First Name and Last Name *

Parent/Guardian Email *

Emergency Contact

First and Last Name of Contact *

Relation to Individual *

Your relation to this person

Phone Number *

Primary

Medical Information

Allergies/Special Health Considerations *

Vehicle Information

License Plate *

Make *

Model *

Carpool Contacts

First and Last Name of Carpooler

Phone Number