Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Primary Telephone *

(###)

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Please check any conditions that may apply

Diabetes

Cardiac illness/history of angina or heart problems

High/low blood pressure

Abnormal bleeding

Previous cold injuries

Musculoskeletal problems

Migraines

Emergency Contact *

First Name

Last Name

Emergency Contact Primary Phone Number *

(###)

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Emergency contact secondary phone number

(###)

###

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Doctors/Hospital phone

(###)

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*

I signify that this information is accurate

I will inform Atna Adventures if anything changes between now and the trip