Release Of Liability / Assumption Of Risk Form (Page 3 of 7) in pdf

Release Of Liability / Assumption Of Risk Form Page 3

Petra Cliffs Mountaineering School Health Questionnaire

The programs that Petra Cliffs offers are, by their nature, physically demanding. Also, these programs

take place in remote locations where advanced medical care is not quickly available. For our guides

to conduct these programs it is essential that we be fully aware of any health issues regarding our

participants. Your responses will be kept in the strictest of confidence. Please call Petra Cliffs

Climbing Center at 657-3872 with any questions. Please complete and send to:

Petra Cliffs Mountaineering School, 105 Briggs St. Burlington VT, 05401 or FAX 802-657-3877

Name:

________________________

Date:

______

Age: ______

Emergency Contact Name and Phone:

(

)

Relation:

Height:_____ Weight:_____ Doctor’s Name and Phone:

(

)

__ __

Do you hold health insurance?: ( )no ( )yes Provider:__________________ ID#:______________

Are you allergic to anything?

Do you currently take any prescription or OTC medications? If yes, what are they for?

Please describe any medical conditions that limit your physical activity:

Please list the dates of your past hospital visits and the describe the associated illness/injury:

Please list any dietary restrictions:

Please describe your level of physical fitness, outlining your daily amount of exercise:

Petra Cliffs Mountaineering School

105 Briggs Street

Burlington, VT 05401

(802) 657-3872 Toll-free: (866) 657-3872

Fax: (802) 657-3877

Release Of Liability / Assumption Of Risk Form Page 3