Eagle Mount Participant Application

Applicant Information
Legal First Name*
Last Name*
Prefer to be called*
We love 'Putting a face to the name.' If possible, Please take a picture of the applicant. This photo will only be used in our internal database so Eagle Mount employees know who is participating.
Date of Birth*

MonthDayYear
Since you are under 18 years old, please have a parent/guardian fill this application out for you. In addition, please restart the application from the beginning.
Gender*

MaleFemalePrefer to Self-DefinePrefer to not disclose
How does the applicant identify?*
Applicant's mailing address*
Applicant's Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Applicant's email*
Please double check! Our initial contact is via email!
Applicant's phone number*
Mobile phone
Home phone
business phone
Preferred Contact Method*

Phone (at a phone number provided above)Email (at email provided above)Text (at mobile phone number provided above)
Is the applicant a veteran?

YesNo

Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Relationship*

ParentSpouseSignificant otherSiblingExtended familyFriendOther
Parent/Guardian Phone*
Parent/Guardian email*
Please double check! Our initial contact is via email!

Billing Information

Our programs have a wide range of available options to pay, and we offer scholarships for most programs to those that qualify. Please enter details for where we can send an invoice if and when necessary.
Payment Party*

First NameLast Name
Billing Address*
Billing Address

Street Address

Street Address Line 2

CityState

Zip Code

Physician Approval

Eagle Mount requires that all participants have a physician's approval on file before participating. Physician Approvals do not expire, however we reserve the right to ask for a new one in cases of major health or behavioral changes. Please answer the following questions to determine if we need to collect a Physician's Approval from you.
Has the applicant engaged with Eagle Mount since October of 2021?*

YesNo
To the best of your knowledge, does the applicant already have a physician approval form on file at Eagle Mount?*

YesNo
Has the applicant had any major changes in health or behavior in the past 12 months?*

YesNo
Has the applicant had any major surgeries in the last 12 months?*

YesNo
The answers above indicate that the applicant does NOT need to turn in a physician approval form.

However, this application will be reviewed in person, and a different determination may be made. We will reach out, but feel free to contact us with additional questions.
The answers above indicate that the applicant DOES need to turn in a physician approval form.

Your form will be auto generated and emailed to the address supplied earlier. Please have the applicant's physician review the form, and return it to us.
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
Signature*

Clear
Date Signed*

MonthDayYear
Should be Empty:

Applicant Information

Parent/Guardian Information

Emergency Contact Information

Billing Information

Disability INformation

Health Precautions

Physician Approval