Medical-Summer

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’.  Rock climbing can be physically and mentally demanding. 

Do you currently have or have you had a history of:

  1. Hypertension                           No      Yes     
  2. Heart attack or heart disease  No       Yes
  3. Heart Palpitations or murmur No       Yes
  4. Chest pain / pressure              No       Yes
  5. Stroke                                     No       Yes
  6. Smoking                                  No       Yes
  7. Diabetes                                  No       Yes
  8. Respiratory problems             No       Yes
  9. Gastrointestinal concerns       No       Yes
  10. Genitourinary concerns          No       Yes
  11. Bleeding or blood disorders    No       Yes
  12. Infectious diseases                 No       Yes
  13. Neurologic problems/seizuresNo        Yes
  14. Dizziness or fainting               No       Yes
  15. Mental health concerns          No       Yes
  16. Recent Illnesses                      No       Yes
  17. Joint or extremity pain / injury No       Yes
  18. Spine pain or injury                 No       Yes
  19. Dietary restrictions                  No       Yes
  20. Eating disorders                      No       Yes
  21. Frostbite or cold injury            No       Yes
  22. Heat injury                               No       Yes
  23. Altitude illness                         No       Yes
  24. Major Surgery                         No       Yes
  25. Physical disability                    No       Yes
  26. Any other health concerns     No       Yes
  1. Are you currently under the care of a medical professional? No       Yes
  2. Are you pregnant?                                                                  No       Yes
  3. Allergies? (insects, food, drugs)                                             No       Yes
  4. 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

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Describe your current physical fitness and level of activity:  _________________________________________________________________________________________________________

In accordance with Federal law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, disability, and where applicable, family status, political beliefs, religion, sexual orientation, genetic information, and reprisal or retaliation for prior civil rights activity. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TTY).

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, Fax or Mail to Tahoe Mountain School, PO Box 1976, Truckee, CA  96160.  info@tahoemountainschool.com Phone:530-414-5295. Fax: 267.645.6181

 

 

Tahoe Mountain School

PO Box 1976

Truckee, CA 96160

Ph. 530-414-5295

info@tahoemountainschool.com