January 23-24, 2021 – Chauvin Guides International LLC

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Mobile Phone *

Home Phone

Email *

Emergency Contact Name *

Emergency Contact's Phone # *

Date of Birth (mm/dd/yyyy) *

Gender *

Height *

Weight *

Physical Condition *

Excellent
Good
Fair
Poor

Outdoor Experience *

Have you been ill or hospitalized in the last 6 months? *

If Yes, please explain.

Do you take any medications regularly? *

If Yes, please describe.

Medical Conditions (Select any that apply) *

If 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? *

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? *

If Yes, please describe.

Is there any other medical or physical concern that might impact your ability to fully enjoy your guided experience? *

If Yes, please describe.

How Will You Be Traveling in Avalanche Terrain? *

Which Remote Class Do You Plan On Attending (All classes are 6-9pm Eastern) *