January 16-17, 2021 * Required Field Please enable JavaScript in your browser to complete this form.Name *FirstLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMobile Phone *Home Phone Email *Emergency Contact Name *Emergency Contact's Phone # *Date of Birth (mm/dd/yyyy) *Gender *Height *Weight *Physical Condition *ExcellentGoodFairPoorOutdoor Experience *Have you been ill or hospitalized in the last 6 months? *Please ChooseYesNoIf Yes, please explain.Do you take any medications regularly? *Please ChooseYesNo If Yes, please describe.Medical Conditions (Select any that apply) *Anaphylaxis/AllergiesAsthmaDiabetesHeart DiseaseSeizuresNone Of The AboveIf you checked any of the above conditions please respond to the next 4 questions.How long have you had the above condition? Is the condition under control?Do you take any medications related to the condition? If you have allergies, what are you allergic to?Do you have any problems with your hearing or vision? *Please ChooseYesNo If Yes, please describe. Do you have any muscular or skeletal deficiencies or recent surgeries that might hinder your mobility and ability to participate in your guided trip? *Please ChooseYesNo If Yes, please describe. Is there any other medical or physical concern that might impact your ability to fully enjoy your guided experience? *Please ChooseYesNo If Yes, please describe. How Will You Be Traveling in Avalanche Terrain? *Alpine Touring Skis and SkinsSplit Board and SkinsSnow Board and SnowshoesTelemark Skis and SkinsHiking and SnowshoesWhich Remote Class Do You Plan On Attending (All classes are 6-9pm Eastern) *Tue Dec 22, 2020Mon Jan 4, 2021Tue Jan 5, 2021Thurs Jan 14, 2021Submit