Performance Adventure Racing – Race Date: _____________

                             _______________________________________________

Team Member (Full Name):

                            _______________________________________________

Email address: _______________________________________________________

Address:           _______________________________________________

City, State, Zip _______________________________________________

Home Phone: _____________________ Business Phone: ____________________

Birth date: __________ Age: ______  Gender: ________

__________________________________________________________________________________

Medical Information

Your (REAL) height:  ____________  Your (REAL) weight: ____________

Blood Type: ________________ Do you wear contact lenses? _____________

If you have any questions regarding your participation in an adventure race, then please discuss them with your physician.

Do you have (circle):

YES NO   Allergies (including medications, foods, and/or insect bites)? Please list:

_______________________________________________________________________________

If allergic to bee stings, do you carry medication?  ____  What medication? ______________________________________________________________________

YES NO   Heart Disease?

YES NO   Diabetes?

YES NO   Chest pain with physical exertion?

YES NO   High blood pressure?

YES NO   Epilepsy?

YES NO   Asthma?

YES NO   Do you smoke?

YES NO   Back problems? Please explain: __________________________________________________________________

YES NO   Dislocations? Please explain: ____________________________________________________________________

YES NO   Are you pregnant? How many months? ___________

YES NO   Have you ever had a heart attack or stroke? Please explain: __________________________________________

YES NO   Are you currently under a doctor’s care? Please explain: _____________________________________________

YES NO   Are you taking any medication? What type/what for? _______________________________________________

Describe your health: _______________________________________________________________

__________________________________________________________________________________

Describe any medical condition, special consideration, or limitation, which might affect your health, participation, or the well being of others. ________________________________________________

__________________________________________________________________________________

I hereby state that I am medically fit and properly trained to participate in a challenging endurance contest such as this Performance Adventure Racing event. I have read and understand the concepts of this event and its rules and requirements. I am taking responsibility for my medical condition and preparation and do not hold any race manager, race director, volunteer, sponsor, or medical staff responsible for my condition or the outcome of my participation in this event.