Tahoe Mountain School
MEDICAL AND EMERGENCY CONTACT INFORMATION
First Name:_________ ___________Last Name: ______________________________________
Today’s Date: ______________
Address: _____________________________ City: ____________________ State: ____
Zip: _______________
Height: ____ Weight: ____ Sex: ____ Date of Birth: _________ Email: ___________________________
Cell Phone: ___________________
Emergency Contact Information
Name: _______________________________Relationship: __________Day Phone: _______________
Physical Address: ________________________________________________ Evening Phone: __________
City: ____________________ State: ____ Email: _______________________ Cell Phone: ___________
TMS courses require at least a moderate level of physical fitness. Weather conditions can vary greatly from very warm to very cold with different types of precipitation and potentially harsh conditions. Our elevation will range from 6000’ to 8000’. Climbing and skiing can be physically and mentally demanding.
Do you currently have or have you had a history of:
- Hypertension No Yes
- Heart attack or heart disease No Yes
- Heart Palpitations or murmur No Yes
- Chest pain / pressure No Yes
- Stroke No Yes
- Smoking No Yes
- Diabetes No Yes
- Respiratory problems No Yes
- Gastrointestinal concerns No Yes
- Genitourinary concerns No Yes
- Bleeding or blood disorders No Yes
- Infectious diseases No Yes
- Neurologic problems/seizuresNo Yes
- Dizziness or fainting No Yes
- Mental health concerns No Yes
- Recent Illnesses No Yes
- Joint or extremity pain / injury No Yes
- Spine pain or injury No Yes
- Dietary restrictions No Yes
- Eating disorders No Yes
- Frostbite or cold injury No Yes
- Heat injury No Yes
- Altitude illness No Yes
- Major Surgery No Yes
- Physical disability No Yes
- Any other health concerns No Yes
- Are you currently under the care of a medical professional? No Yes
- Are you pregnant? No Yes
- Allergies? (insects, food, drugs) No Yes
- Are you currently using or carrying any medications? No Yes
If you answered yes to any of the above questions please describe below. Use additional pages if necessary
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Describe your current physical fitness and level of activity: _________________________________________________________________________________________________________
To the best of my knowledge, the above information is a complete and accurate representation of my pertinent medical history. I declare that I am in good physical health and believe that I am able without reservation or limiting conditions to physically withstand and cope with the indicated rigors of this program. In the event of an emergency, permission is given for any evacuation, medical intervention and care that may become necessary for my immediate well being.
Participant Signature: _________________________________
Email or Mail to Tahoe Mountain School, PO Box 1976, Truckee, CA 96160. info@tahoemountainschool.com Phone:530-414-5295.