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Medical Form

Medical Form2016-12-23T19:52:37-08:00

Step 1 of 2

50%
  • Rock/ice climbing, skiing, backcountry skiing, mountaineering, wilderness hiking, gym climbing etc…
  • Please describe your physical conditioning program, if any.
  • Please describe your physical condition.
  • If this is a program where SMC is providing food, do you have any special dietary needs or requests? Are you Vegan/Dairy Free/Gluten Free/Egg Free/Vacuum Eater? If none of the above, just put N/A.
  • EMERGENCY CONTACT INFORMATION

  • MEDICAL PROVIDER & INSURANCE

    Please provide details about your medical provider.
  • MEDICAL HISTORY

    Do you now have, or have you had within the past two years, any of the following conditions?
    If “yes” to any of the conditions below, please explain in the space provided.
    SMC requires face masks be worn any time during a trip when social distancing is impossible.
    SMC requires face masks be worn any time during a trip when social distancing is impossible.
    SMC requires face masks be worn any time during a trip when social distancing is impossible.
    SMC requires face masks be worn any time during a trip when social distancing is impossible.
  • We find that sometimes people fail to assess their health and abilities fully or honestly and end up suffering on an outdoor trip at elevation.
Save and Continue Later
    Do you work, play, or live in a Covid-19 high-risk environment?
  • Do you agree to inform SMC office staff and/or guides if you begin experiencing any of the above symptoms, at any time before, during or after your scheduled trip?
  • Do you agree to follow the guidelines given to you by SMC and your guide, and that failure to comply with these guidelines may result in the early termination of your trip?
  • SMC may take temperature and oxygen saturation levels at the beginning of the trip and at periodic times throughout the duration of your trip. These checks are not invasive and you can perform them on yourself if desired.
  • After the trip SMC may follow up by phone or email to ask if you are showing any Covid-19 symptoms.
  • Please sign to confirm your cooperation with our Covid-19 risk reduction plans (as indicated by your consents above).
  • This field is for validation purposes and should be left unchanged.
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Sierra Mountain Center
Sierra Mountain Center, LLC

Bishop, California USA
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"In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability. (Not all prohibited bases apply to all programs.) To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer." SMC operates under permits from Inyo National Forest, Yosemite National Park, Toiyabe National Forest, Joshua Tree National Park, Sequoia and Kings Canyon National Parks, and other agencies as required.
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