continued from Page 1 Name:__________________________ Date of Birth: YY ____ MM ___ DD ___ Previous history of cold injury, e.g. frostbite, trenchfoot etc.: No____ Yes ____ if yes, please describe: __________________ Previous history of heat injury, e.g. hyperthermia, heat or sunstroke etc.: No____ Yes ____ if yes, please describe: __________________ Previous history of altitude illness: No____ Yes ____ if yes, please describe: __________________ Date* of last tetanus shot or booster: YY____ MM _____ DD ______ *Current (within 10 years) is required for any trip 3 days or longer

I, ________________________________ please print your name have honestly disclosed all of the information requested in the above questions; and, I understand that withholding information may contribute to injury or illness complications and possibly compromise the care provided in the event of an emergency. If any of the above information changes prior to or during the trip, I will immediately notify Tom Carter of Moon Mountain Adventures. Date:___________________ Signature:_________________ If the participant is under 19 years of age, a parent or guardian must sign: Print name of parent or guardian: ___________________ Signature of parent or guardian: _____________________