For your convenience, you may copy and paste this form to an email. In return, High Ice Ak will send you an information package to include a "Release" to read and sign.

Name________________________________________________________Age___________

Address___________________________________________________________________

City____________________________________ State_________ Zip__________________

Phone Number_____________________ Email Address_____________________________

Course Name_________________ Course Date_________________ Deposit___________

Emergency Contact________________________________________________________

Relationship____________________________________Phone_______________________

Outdoor/Climbing Experience__________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Do you train or work out regularly?_______________________________________________

Your Assessment of Your Health_________________________________________________

Past Medical Illnesses Injuries___________________________________________________

Food or Drug Alergies_________________________________________________________

Will you need to rent gear? _______What?_________________________Where?__________

How did you hear about High Ice Ak?___________________________________________

Would you be a reference for future students?______________________________________

Can photos taken of you while climbing with High Ice Ak be used for advertisements?________