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Domestic Registration Form

Please complete this application for any trips taking place in the United States with the exception of Alaska Programs. In order to process your application and schedule your trip, we must receive a complete application along with the appropriate deposit or final payment amount. Call the office at 509-548-5823 or send an e-mail to olivia@mountainschool.com with any questions.

Note: All information provided will be kept confidential and will not be transferred to 3rd parties
Fields with bold labels must be completed before your application can be processed

Program


Program Name:
Program Start Date:
Program End Date:

Your Information
Your Name:
Prefer to be Called:
Gender:	none
Address:
	,
Home Phone:
Cell Phone:
Work Phone:
Email Address:
Best Contact Method:	none
Date of Birth:
Occupation:

Group Information
Add names of additional participants (if any), separated with a comma
*NOTE ON GROUP REGISTRATIONS: One person may register an entire group, but they become responsible for all payments, and for ensuring all group members have reviewed the Release of Liability and Assumption of Risk Agreement ("Release Agreement") before committing to the program. Each participant will be required to sign a Release Agreement and complete medical information forms before the program begins. Release Agreements are available here: Registration Information.

Parent/Guardian Information
Parent Name:
Parent Title:	none
Parent Attending:	Yes, the parent/guardian will be attending with his/her child
Parent Address:
	,
Home Phone:
Cell Phone:
Work Phone:
Email Address:

Emergency Contact Information
Contact Name:
Relationship to You:
Contact Address:
	,
Home Phone:
Cell Phone:
Work Phone:
Email Address:

Mountaineering or Skiing Experience
Please list your previous mountaineering or skiing experience, and any other activities related to this program (i.e. ski ability, hiking, etc.):

Participant Medical Information
Please answer each question, providing detailed information on dates and type of medical treatment. For family & small group applications (4 or fewer persons), please answer each of the following questions for each participant, listing each person by name. For larger groups we will collect this information separately.
List any major accidents, illnesses, or operations you have had in the past 5 years:
List any/all physical limitations or medical conditions that may restrict your ability to climb on this program:
List any/all medications (including dosages) you will be taking on this trip and why:
List any/all allergies to food and/or medication:
Are there any foods that you do not eat?

Participant Information - Other Information
How did you hear about the Northwest Mountain School?

Insurance Information
Travel Insurance:	I have purchased Travel Insurance for this program
Travel Policy Info:

Terms and Conditions
In order to register for any Northwest Mountain School program, you must read, understand and accept the following: NMS Terms and Conditions NMS Release Form Click the above links to read and print these documents.

Accepted:	By checking this box I confirm that I agree to the NMS Terms and Conditions and the Release of Liability and Assumption of Risk Agreement
Signature:	Dated:

Domestic Registration Form

Northwest Mountain School