Your Name: Company Address City State Zip Code Country E-mail Phone Your Fitness Level: Height/Weight: T-shirt/Shoe size
Emergency Contact: Relation to Applicant: Emergency Contact Phone Number:
Insurance Carrier Policy Number Company Phone Company Address
Arrival Date & Time Airline & Flight Number Departure Date & Time Do you require a pick-up from Canyonlands Field Airport?
We recommend that you consult your physician regarding your participation in one of our retreats. Please contact us if you have ANY questions regarding your ability to participate. What is your present state of health? Do you have any pre-existing medical conditions? Do you currently take any medications and if so, which ones? Do you have any pre-existing injuries we should be aware of? Are you pregnant and if so, how many months? Do you have any allergies? Do you require Vegetarian fare?
Please note that each of our retreats vary in difficulty (see descriptions). What kind of physical condition would you say you are in? Include activities in which you participate in and the frequency of each activity.
What most interests you about our retreats? What would you like to get out of this experience? Do you have any experience hiking at elevations above 5,000 ft? If so, when and where? (No experience is required). *For Base Camp / Backpack Retreats Only* What fuel type do you use for your stove? Do you have any experience rock climbing? Please explain. (No experience is required) Do you have any concerns or apprehensions about our retreats? How did you learn about us? Comments
