Annual Volunteer Application

EMERGENCY CONTACT INFORMATION
Emergency Contact*

First NameLast Name
Relationship*

MotherFatherSpouseSignificant OtherSiblingFriendOther
Emergency Contact Primary Phone Number*

Health Precautions

Basic health information is collected to ensure we have the information necessary to designing a safe, fun, empowering recreational experience.
ACKNOWLEDGMENTS:*

I acknowledge that it is my responsibility to confirm with my medical team to ensure it is safe for the applicant to partake in Eagle Mount activities. I take responsibility for being honest and forthcoming in my responses to the following questions, and understand that it is within Eagle Mount's sole discretion to request a Physician Approval Form if necessary.
Does the applicant have Allergies?
Please List all of the applicant's known allergies:*

0/500
Has the applicant gone into Anaphylactic shock due to an allergic reaction?
Does the applicant carry an EPIPEN?
How are the applicant's allergic reactions treated?*

0/500
Does the applicant have Asthma?
Does the applicant carry an inhaler?
Has the applicant ever sought emergency care due to an asthma attack?
When did the applicant last seek emergency care due to an asthma attack?*

MonthDayYear
What were the circumstances?*

0/500
How are the applicant's asthma attacks treated?*

0/500
Does the applicant have Diabetes?
What type(s)?*

Type IType II
Is the applicant insulin dependent?
Does the applicant have an insulin pump?
How are the applicant's diabetic episodes treated?*

0/500
Is the applicant subject to seizures?
What types of seizures does the applicant experience?*
How frequently?*
How are the applicant's seizures treated?*

0/500
Does the applicant have a shunt?
Please describe the applicant's shunt type and location:*

0/500
Does the applicant have a gastronomy tube?
Does the applicant have a catheter?
Please describe the applicant's catheter type:*

0/500
Does the applicant have a history of heart disease, heart condition, or high blood pressure?
Please describe the condition and any medications or treatment the applicant is receiving:*

0/500
Does the applicant have a history of bone or joint disorder?
Please describe the condition and any medications or treatment the applicant is receiving*

0/500
Has the applicant experienced a spinal cord injury and/or fusion?
Please describe the condition, location, and any medications or treatment the applicant is receiving:*

0/500
Does the applicant have any history of head injury?
Please describe the condition and any medications or treatments the applicant is receiving:*

0/500
Does the applicant have hemophilia or a tendency to bleed?
How are the applicant's bleeding episodes treated?*

0/500
Does the applicant have any body parts that are susceptible to heat/cold and/or heat exhaustion?
Please describe the condition and any medications or treatment the applicant is receiving:*

0/500
Please share relevant information regarding any other injuries, illnesses, surgeries, or skin breakdown in the last year, or pertinent past surgeries:

0/500
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Name

First NameLast Name
DATE Signed

MonthDayYear
Should be Empty:

Applicant INFORMATION

EMERGENCY CONTACT INFORMATION

Health Precautions