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Registration and Health Form
REGISTRATION AND HEALTH FORM
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First Name
Last Name
Email
Phone
Address 1
Address 2
City
State
Zip/Postal Code
Country
Birthday
Height (in)
Weight (lbs)
Emergency Contact Name
Relationship to You
Emergency Contact Phone Number
Primary Dr. Name
Primary Dr. Phone Number
Medical Insurance Name
Group Number
Individual Number
Do you have any medical allergies such as from medications, insects, etc.?
Yes
No
Please list and include their severity
Do you take any prescription medications?
Yes
No
If so, please list and explain their purpose
Do you have a history of heart problems, respiratory conditions, or any recent illnesses, injuries, hospitalizations, or operations?
Yes
No
If so, please list them
Please list any special dietary requirements or food allergies
Rate your current physical strength and endurance (1 - 5, 1 being poor and 5 being excellent)
1
2
3
4
5
Can you swim well?
Yes
No
Do you smoke?
Yes
No
What best describes your religious background? (i.e. Christian, irreligious, curious/seeking, other)
How did you find out about Backcountry Sojourners?
Is there any other information that we should know about you?
Thank you for contacting us.
We will get back to you as soon as possible
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CONTACT
Nate:
605-310-8241
Tom:
989-316-5515
E-mail:
backcountrysojourners@gmail.com
CONNECT
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